- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $4,168.69
| Facility | | $1,819.70 | $2,344.23 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $3,981.07
| Professional | | $1,819.70 | $2,344.23 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,511.89 / $9,549.93
| Facility | | $1,862.09 | $2,511.89 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,570.40 / $5,248.07
| Professional | | $2,398.83 | $2,570.40 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,388.44 / $17,782.79
| Facility | | $3,235.94 | $3,388.44 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $6,760.83
| Professional | | $2,454.71 | $2,454.71 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $5,495.41
| Facility | | $2,290.87 | $3,162.28 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $3,467.37
| Professional | | $1,659.59 | $2,238.72 | $3,467.37 |