- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $3,235.94
| Facility | | $1,445.44 | $1,862.09 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $3,235.94
| Professional | | $1,445.44 | $1,905.46 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,995.26 / $7,943.28
| Facility | | $1,479.11 | $1,995.26 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,995.26 / $4,168.69
| Professional | | $1,949.84 | $1,995.26 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $14,454.40
| Facility | | $2,570.40 | $2,570.40 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $5,623.41
| Professional | | $1,862.09 | $1,862.09 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,398.83 / $4,365.16
| Facility | | $1,513.56 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,778.28 / $2,691.53
| Professional | | $1,288.25 | $1,778.28 | $2,691.53 |