- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,449.43 / $1,449.43 / $3,045.61
| Facility | | $1,449.43 | $1,449.43 | $3,045.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.14 / $1,449.43 / $1,507.41
| Professional | | $1,300.14 | $1,449.43 | $1,507.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,406.03 / $2,725.82 / $3,045.61
| Facility | | $2,406.03 | $2,725.82 | $3,045.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.74 / $1,526.81 / $2,106.98
| Professional | | $1,485.74 | $1,526.81 | $2,106.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,284.21 / $3,350.17 / $4,263.85
| Facility | | $2,284.21 | $3,350.17 | $4,263.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,588.77 / $3,350.17 / $4,111.57
| Professional | | $2,588.77 | $3,350.17 | $4,111.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.51 / $2,119.51 / $3,045.61
| Facility | | $2,119.51 | $2,119.51 | $3,045.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.24 / $2,119.51 / $2,777.53
| Professional | | $1,547.24 | $2,119.51 | $2,777.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.06 / $1,519.42 / $2,133.31
| Professional | | $835.06 | $1,519.42 | $2,133.31 |