- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,905.46 / $3,235.94
| Facility | | $1,380.38 | $1,905.46 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $3,235.94
| Professional | | $1,348.96 | $1,905.46 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $7,413.10
| Facility | | $1,445.44 | $1,949.84 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,949.84 / $4,265.80
| Professional | | $1,905.46 | $1,949.84 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $14,454.40
| Facility | | $2,454.71 | $2,454.71 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $5,495.41
| Professional | | $1,819.70 | $1,819.70 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $4,365.16
| Facility | | $1,698.24 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $2,754.23
| Professional | | $1,288.25 | $1,819.70 | $2,754.23 |