- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,372.50 / $2,030.16 / $2,095.16
| Facility | | $1,372.50 | $2,030.16 | $2,095.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.50 / $1,572.66 / $2,859.38
| Professional | | $1,372.50 | $1,572.66 | $2,859.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,004.13 / $3,154.34 / $13,867.06
| Facility | | $3,004.13 | $3,154.34 | $13,867.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.45 / $1,647.60 / $2,431.61
| Professional | | $1,533.45 | $1,647.60 | $2,431.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,952.91 / $1,952.91 / $1,952.91
| Facility | | $1,952.91 | $1,952.91 | $1,952.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.62 / $1,425.62 / $2,081.90
| Professional | | $1,425.62 | $1,425.62 | $2,081.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,372.50 / $2,421.08 / $14,058.21
| Facility | | $1,372.50 | $2,421.08 | $14,058.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.21 / $1,605.81 / $2,666.91
| Professional | | $1,121.21 | $1,605.81 | $2,666.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.75 / $1,498.72 / $2,073.29
| Professional | | $1,143.75 | $1,498.72 | $2,073.29 |