- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,949.84 / $3,801.89
| Facility | | $1,584.89 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $3,162.28
| Professional | | $1,584.89 | $1,905.46 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,089.30 / $7,413.10
| Facility | | $1,513.56 | $2,089.30 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,290.87 / $4,365.16
| Professional | | $1,995.26 | $2,290.87 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $14,791.08
| Facility | | $2,290.87 | $2,290.87 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $5,370.32
| Professional | | $1,659.59 | $1,659.59 | $5,370.32 |
- 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
- $1,380.38 / $1,862.09 / $2,884.03
| Professional | | $1,380.38 | $1,862.09 | $2,884.03 |