- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $5,011.87
| Facility | | $1,548.82 | $2,041.74 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $3,388.44
| Professional | | $1,548.82 | $2,041.74 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $7,943.28
| Facility | | $1,584.89 | $2,137.96 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,187.76 / $4,570.88
| Professional | | $1,995.26 | $2,187.76 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $15,488.17
| Facility | | $2,137.96 | $2,137.96 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $6,025.60
| Professional | | $1,584.89 | $1,584.89 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $4,677.35
| Facility | | $1,949.84 | $2,630.27 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,949.84 / $2,951.21
| Professional | | $1,412.54 | $1,949.84 | $2,951.21 |