- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,041.74 / $3,467.37
| Facility | | $1,659.59 | $2,041.74 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,041.74 / $3,311.31
| Professional | | $1,659.59 | $2,041.74 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,187.76 / $7,762.47
| Facility | | $1,584.89 | $2,187.76 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,137.96 / $4,786.30
| Professional | | $2,041.74 | $2,137.96 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $16,218.10
| Facility | | $2,511.89 | $2,511.89 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $5,754.40
| Professional | | $1,862.09 | $1,862.09 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,691.53 / $4,786.30
| Facility | | $1,737.80 | $2,691.53 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $3,019.95
| Professional | | $1,445.44 | $1,949.84 | $3,019.95 |