- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,341.23 / $1,341.23 / $2,818.25
| Facility | | $1,341.23 | $1,341.23 | $2,818.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.58 / $1,341.23 / $1,394.88
| Professional | | $1,154.58 | $1,341.23 | $1,394.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,226.42 / $2,522.33 / $2,818.25
| Facility | | $2,226.42 | $2,522.33 | $2,818.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.07 / $1,425.16 / $1,966.72
| Professional | | $1,401.07 | $1,425.16 | $1,966.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.85 / $2,959.16 / $3,945.55
| Facility | | $1,982.85 | $2,959.16 | $3,945.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.51 / $3,100.08 / $3,804.64
| Professional | | $2,395.51 | $3,100.08 | $3,804.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.10 / $1,823.10 / $2,818.25
| Facility | | $1,823.10 | $1,823.10 | $2,818.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,823.10 / $2,867.04
| Professional | | $1,330.86 | $1,823.10 | $2,867.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.86 / $1,405.99 / $1,863.79
| Professional | | $775.86 | $1,405.99 | $1,863.79 |