- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.70 / $2,172.96 / $2,259.88
| Facility | | $1,659.70 | $2,172.96 | $2,259.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.08 / $2,401.92 / $3,068.38
| Professional | | $1,940.08 | $2,401.92 | $3,068.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,842.29 / $4,565.92 / $4,798.78
| Facility | | $2,842.29 | $4,565.92 | $4,798.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,307.29 / $2,742.31 / $2,884.11
| Professional | | $2,307.29 | $2,742.31 | $2,884.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,424.44 / $6,437.95 / $8,675.25
| Facility | | $3,424.44 | $6,437.95 | $8,675.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,565.92 / $6,163.99 / $8,059.28
| Professional | | $4,565.92 | $6,163.99 | $8,059.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $5,988.79
| Facility | | $2,853.06 | $2,853.06 | $5,988.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $25,100.82
| Professional | | $2,082.73 | $2,853.06 | $25,100.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,386.17 / $2,909.97 / $3,637.46
| Professional | | $2,386.17 | $2,909.97 | $3,637.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.59 / $2,441.14 / $3,652.74
| Professional | | $1,518.59 | $2,441.14 | $3,652.74 |