- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,145.35 / $1,145.35 / $1,145.35
| Facility | | $1,145.35 | $1,145.35 | $1,145.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.59 / $1,274.11 / $1,634.00
| Professional | | $638.59 | $1,274.11 | $1,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.31 / $2,100.00 / $2,100.00
| Professional | | $976.31 | $2,100.00 | $2,100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,719.06 / $2,403.41 / $3,008.36
| Facility | | $1,719.06 | $2,403.41 | $3,008.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.66 / $2,403.41 / $3,862.62
| Professional | | $1,831.66 | $2,403.41 | $3,862.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,014.52 / $2,014.52 / $2,014.52
| Facility | | $2,014.52 | $2,014.52 | $2,014.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $2,023.15
| Professional | | $742.34 | $742.34 | $2,023.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.58 / $1,095.58 / $1,095.58
| Professional | | $1,095.58 | $1,095.58 | $1,095.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.37 / $856.46 / $1,133.30
| Professional | | $514.37 | $856.46 | $1,133.30 |