- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,190.22 / $1,558.29 / $1,620.62
| Facility | | $1,190.22 | $1,558.29 | $1,620.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.29 / $1,726.91 / $2,104.83
| Professional | | $1,391.29 | $1,726.91 | $2,104.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,038.29 / $3,274.36 / $3,441.35
| Facility | | $2,038.29 | $3,274.36 | $3,441.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,582.74 / $1,966.59 / $2,000.39
| Professional | | $1,582.74 | $1,966.59 | $2,000.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,455.77 / $4,616.85 / $6,221.28
| Facility | | $2,455.77 | $4,616.85 | $6,221.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,274.36 / $4,420.39 / $5,528.46
| Professional | | $3,274.36 | $4,420.39 | $5,528.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,694.60 / $2,694.60 / $4,280.45
| Facility | | $2,694.60 | $2,694.60 | $4,280.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.06 / $2,499.61 / $17,940.66
| Professional | | $1,967.06 | $2,499.61 | $17,940.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,711.19 / $2,086.82 / $2,608.52
| Professional | | $1,711.19 | $2,086.82 | $2,608.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.03 / $1,675.85 / $2,517.23
| Professional | | $1,089.03 | $1,675.85 | $2,517.23 |