- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,604.39 / $1,604.39 / $1,925.27
| Facility | | $1,604.39 | $1,604.39 | $1,925.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.95 / $1,244.96 / $1,604.39
| Professional | | $1,194.95 | $1,244.96 | $1,604.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,849.36 / $2,849.36 / $3,377.63
| Facility | | $2,849.36 | $2,849.36 | $3,377.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.84 / $1,500.84 / $1,567.70
| Professional | | $1,500.84 | $1,500.84 | $1,567.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.76 / $1,960.76 / $1,960.76
| Facility | | $1,960.76 | $1,960.76 | $1,960.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.35 / $1,431.35 / $2,090.26
| Professional | | $1,431.35 | $1,431.35 | $2,090.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,307.00 / $2,307.00 / $7,120.56
| Professional | | $2,307.00 | $2,307.00 | $7,120.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.68 / $1,421.51 / $2,270.30
| Professional | | $947.68 | $1,421.51 | $2,270.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,134.08 / $2,347.48 / $2,987.71
| Professional | | $2,134.08 | $2,347.48 | $2,987.71 |