- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,301.71 / $1,301.71 / $2,735.22
| Facility | | $1,301.71 | $1,301.71 | $2,735.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.35 / $1,327.74 / $1,353.78
| Professional | | $1,200.35 | $1,327.74 | $1,353.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.82 / $2,448.02 / $2,735.22
| Facility | | $2,160.82 | $2,448.02 | $2,735.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.36 / $1,481.65 / $2,044.67
| Professional | | $1,370.36 | $1,481.65 | $2,044.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,051.42 / $3,008.74 / $3,829.31
| Facility | | $2,051.42 | $3,008.74 | $3,829.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,324.94 / $3,008.74 / $3,692.55
| Professional | | $2,324.94 | $3,008.74 | $3,692.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.38 / $1,769.38 / $2,735.22
| Facility | | $1,769.38 | $1,769.38 | $2,735.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.65 / $1,769.38 / $2,805.81
| Professional | | $1,291.65 | $1,769.38 | $2,805.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.62 / $1,364.57 / $1,864.47
| Professional | | $806.62 | $1,364.57 | $1,864.47 |