- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,819.70 / $3,235.94
| Facility | | $1,348.96 | $1,819.70 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,862.09 / $3,235.94
| Professional | | $1,348.96 | $1,862.09 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $7,585.78
| Facility | | $1,412.54 | $1,905.46 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,905.46 / $4,265.80
| Professional | | $1,862.09 | $1,905.46 | $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
- $2,041.74 / $2,344.23 / $4,265.80
| Facility | | $2,041.74 | $2,344.23 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,778.28 / $2,630.27
| Professional | | $1,288.25 | $1,778.28 | $2,630.27 |