- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $3,630.78
| Facility | | $1,513.56 | $2,041.74 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $3,388.44
| Professional | | $1,513.56 | $2,041.74 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,089.30 / $7,943.28
| Facility | | $1,548.82 | $2,089.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,137.96 / $4,570.88
| Professional | | $2,041.74 | $2,137.96 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $16,218.10
| Facility | | $2,754.23 | $2,754.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $6,165.95
| Professional | | $2,041.74 | $2,041.74 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,570.40 / $4,570.88
| Facility | | $1,659.59 | $2,570.40 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,949.84 / $2,951.21
| Professional | | $1,412.54 | $1,949.84 | $2,951.21 |