- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $3,548.13
| Facility | | $1,737.80 | $2,089.30 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $3,467.37
| Professional | | $1,737.80 | $2,089.30 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,290.87 / $8,128.31
| Facility | | $1,659.59 | $2,290.87 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $4,897.79
| Professional | | $2,137.96 | $2,290.87 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $15,135.61
| Facility | | $2,290.87 | $2,290.87 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $5,888.44
| Professional | | $1,659.59 | $1,659.59 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,818.38 / $5,011.87
| Facility | | $1,995.26 | $2,818.38 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $3,162.28
| Professional | | $1,513.56 | $2,041.74 | $3,162.28 |