- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $4,265.80
| Facility | | $1,584.89 | $2,137.96 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $3,548.13
| Professional | | $1,584.89 | $2,137.96 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $8,709.64
| Facility | | $1,698.24 | $2,290.87 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,238.72 / $4,786.30
| Professional | | $2,137.96 | $2,238.72 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $16,218.10
| Facility | | $2,691.53 | $2,691.53 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $6,165.95
| Professional | | $1,995.26 | $1,995.26 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,818.38 / $5,011.87
| Facility | | $2,238.72 | $2,818.38 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,995.26 / $3,090.30
| Professional | | $1,445.44 | $1,995.26 | $3,090.30 |