- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $3,235.94
| Facility | | $1,258.93 | $1,737.80 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $2,884.03
| Professional | | $1,258.93 | $1,737.80 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,778.28 / $7,079.46
| Facility | | $1,318.26 | $1,778.28 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $3,801.89
| Professional | | $1,737.80 | $1,819.70 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $13,182.57
| Facility | | $2,290.87 | $2,290.87 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $5,128.61
| Professional | | $1,659.59 | $1,659.59 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $3,890.45
| Facility | | $1,778.28 | $2,187.76 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,621.81 / $2,454.71
| Professional | | $1,174.90 | $1,621.81 | $2,454.71 |