- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,389.64 / $2,012.16 / $2,092.64
| Facility | | $1,389.64 | $2,012.16 | $2,092.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.51 / $2,092.64 / $2,716.95
| Professional | | $1,796.51 | $2,092.64 | $2,716.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,631.95 / $4,228.03 / $4,443.66
| Facility | | $2,631.95 | $4,228.03 | $4,443.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,985.22 / $2,296.10 / $2,553.78
| Professional | | $1,985.22 | $2,296.10 | $2,553.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,171.02 / $5,707.84 / $8,033.26
| Facility | | $3,171.02 | $5,707.84 | $8,033.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,228.03 / $5,707.84 / $7,136.23
| Professional | | $4,228.03 | $5,707.84 | $7,136.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.39 / $3,297.39 / $4,954.72
| Facility | | $3,297.39 | $3,297.39 | $4,954.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.09 / $3,297.39 / $20,525.49
| Professional | | $2,407.09 | $3,297.39 | $20,525.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.58 / $2,694.62 / $3,368.27
| Professional | | $2,209.58 | $2,694.62 | $3,368.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.22 / $2,260.48 / $3,382.42
| Professional | | $1,406.22 | $2,260.48 | $3,382.42 |