- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.65 / $1,181.65 / $2,482.94
| Facility | | $1,181.65 | $1,181.65 | $2,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.39 / $1,181.65 / $1,228.92
| Professional | | $1,033.39 | $1,181.65 | $1,228.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,961.52 / $2,222.23 / $2,482.94
| Facility | | $1,961.52 | $2,222.23 | $2,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.97 / $1,275.56 / $1,760.27
| Professional | | $1,243.97 | $1,275.56 | $1,760.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,774.72 / $2,609.88 / $3,476.12
| Facility | | $1,774.72 | $2,609.88 | $3,476.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,110.50 / $2,731.23 / $3,351.97
| Professional | | $2,110.50 | $2,731.23 | $3,351.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,606.19 / $1,606.19 / $2,482.94
| Facility | | $1,606.19 | $1,606.19 | $2,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.52 / $1,606.19 / $2,547.02
| Professional | | $1,172.52 | $1,606.19 | $2,547.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.42 / $1,238.71 / $1,659.04
| Professional | | $694.42 | $1,238.71 | $1,659.04 |