- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $3,311.31
| Facility | | $1,445.44 | $1,862.09 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $3,019.95
| Professional | | $1,445.44 | $1,862.09 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $6,918.31
| Facility | | $1,412.54 | $1,905.46 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,995.26 / $4,265.80
| Professional | | $1,862.09 | $1,995.26 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,570.40 / $14,791.08
| Facility | | $2,454.71 | $2,570.40 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $5,754.40
| Professional | | $1,862.09 | $1,862.09 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,290.87 / $4,168.69
| Facility | | $1,288.25 | $2,290.87 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,737.80 / $2,630.27
| Professional | | $1,288.25 | $1,737.80 | $2,630.27 |