- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,187.76 / $5,623.41
| Facility | | $1,819.70 | $2,187.76 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,290.87 / $3,981.07
| Professional | | $1,819.70 | $2,290.87 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $9,332.54
| Facility | | $1,819.70 | $2,454.71 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,951.21 / $5,370.32
| Professional | | $2,290.87 | $2,951.21 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $16,595.87
| Facility | | $2,454.71 | $2,454.71 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $6,309.57
| Professional | | $1,819.70 | $1,819.70 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,019.95 / $5,370.32
| Facility | | $1,949.84 | $3,019.95 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,238.72 / $3,311.31
| Professional | | $1,584.89 | $2,238.72 | $3,311.31 |