- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,862.09 / $3,630.78
| Facility | | $1,479.11 | $1,862.09 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $2,951.21
| Professional | | $1,445.44 | $1,905.46 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,089.30 / $7,762.47
| Facility | | $1,548.82 | $2,089.30 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,137.96 / $4,466.84
| Professional | | $1,778.28 | $2,137.96 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $13,489.63
| Facility | | $2,137.96 | $2,137.96 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $5,128.61
| Professional | | $1,548.82 | $1,548.82 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,570.40 / $4,570.88
| Facility | | $1,819.70 | $2,570.40 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $2,818.38
| Professional | | $1,380.38 | $1,819.70 | $2,818.38 |