- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $3,548.13
| Facility | | $1,445.44 | $1,949.84 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,995.26 / $3,388.44
| Professional | | $1,445.44 | $1,995.26 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $8,128.31
| Facility | | $1,513.56 | $2,041.74 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,041.74 / $4,570.88
| Professional | | $1,995.26 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,630.27 / $15,488.17
| Facility | | $2,511.89 | $2,630.27 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $5,888.44
| Professional | | $1,905.46 | $1,905.46 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,511.89 / $4,466.84
| Facility | | $1,862.09 | $2,511.89 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $2,818.38
| Professional | | $1,380.38 | $1,862.09 | $2,818.38 |