- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,715.35 / $4,073.80
| Facility | | $2,041.74 | $3,715.35 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $3,715.35
| Professional | | $1,348.96 | $1,659.59 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,380.38 / $1,548.82
| Facility | | $1,318.26 | $1,380.38 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $933.25 / $2,454.71
| Professional | | $870.96 | $933.25 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,454.71
| Facility | | $1,819.70 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $4,570.88
| Professional | | $851.14 | $1,230.27 | $4,570.88 |