- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,568.16 / $1,568.16 / $1,881.79
| Facility | | $1,568.16 | $1,568.16 | $1,881.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.85 / $1,410.63 / $1,671.02
| Professional | | $1,216.85 | $1,410.63 | $1,671.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,785.04 / $2,785.04 / $3,301.39
| Facility | | $2,785.04 | $2,785.04 | $3,301.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.61 / $1,693.61 / $1,777.25
| Professional | | $1,693.61 | $1,693.61 | $1,777.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,125.02 / $2,125.02 / $2,125.02
| Facility | | $2,125.02 | $2,125.02 | $2,125.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.26 / $1,551.26 / $2,125.02
| Professional | | $1,551.26 | $1,551.26 | $2,125.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,254.92 / $2,254.92 / $6,959.81
| Professional | | $2,254.92 | $2,254.92 | $6,959.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.28 / $1,389.43 / $2,219.04
| Professional | | $926.28 | $1,389.43 | $2,219.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,085.90 / $2,294.48 / $2,920.26
| Professional | | $2,085.90 | $2,294.48 | $2,920.26 |