- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $3,162.28
| Facility | | $1,445.44 | $1,862.09 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $3,090.30
| Professional | | $1,412.54 | $1,862.09 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $6,918.31
| Facility | | $1,445.44 | $1,949.84 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,949.84 / $4,168.69
| Professional | | $1,862.09 | $1,949.84 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $14,125.38
| Facility | | $2,398.83 | $2,398.83 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $5,495.41
| Professional | | $1,778.28 | $1,778.28 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,398.83 / $4,265.80
| Facility | | $1,445.44 | $2,398.83 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $2,691.53
| Professional | | $1,258.93 | $1,778.28 | $2,691.53 |