- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,576.13 / $1,673.12 / $2,376.31
| Facility | | $1,576.13 | $1,673.12 | $2,376.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.22 / $1,673.12 / $2,424.81
| Professional | | $1,265.22 | $1,673.12 | $2,424.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.54 / $2,147.54 / $2,147.54
| Professional | | $2,147.54 | $2,147.54 | $2,147.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,538.29 / $4,336.29 / $6,095.24
| Facility | | $2,538.29 | $4,336.29 | $6,095.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,731.02 / $2,070.54 / $2,070.54
| Professional | | $1,731.02 | $2,070.54 | $2,070.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,610.26 / $1,610.26 / $1,610.26
| Facility | | $1,610.26 | $1,610.26 | $1,610.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.00 / $1,800.00 / $1,800.00
| Facility | | $1,800.00 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.00 / $1,800.00 / $1,800.00
| Professional | | $1,314.00 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.04 / $1,483.61 / $1,927.35
| Professional | | $760.04 | $1,483.61 | $1,927.35 |