- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $4,365.16
| Facility | | $1,819.70 | $2,454.71 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,511.89 / $4,365.16
| Professional | | $1,819.70 | $2,511.89 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,630.27 / $10,232.93
| Facility | | $1,905.46 | $2,630.27 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,570.40 / $5,623.41
| Professional | | $2,511.89 | $2,570.40 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $19,498.45
| Facility | | $3,235.94 | $3,235.94 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $7,413.10
| Professional | | $2,398.83 | $2,398.83 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,162.28 / $5,754.40
| Facility | | $1,995.26 | $3,162.28 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $3,548.13
| Professional | | $1,737.80 | $2,344.23 | $3,548.13 |