- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,089.30 / $4,265.80
| Facility | | $1,621.81 | $2,089.30 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,089.30 / $3,548.13
| Professional | | $1,621.81 | $2,089.30 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $8,128.31
| Facility | | $1,698.24 | $2,290.87 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,238.72 / $4,897.79
| Professional | | $2,137.96 | $2,238.72 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $15,848.93
| Facility | | $2,951.21 | $2,951.21 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $6,165.95
| Professional | | $2,187.76 | $2,187.76 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,818.38 / $5,011.87
| Facility | | $2,041.74 | $2,818.38 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $3,090.30
| Professional | | $1,513.56 | $1,995.26 | $3,090.30 |