- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $4,265.80
| Facility | | $1,659.59 | $2,238.72 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,290.87 / $4,168.69
| Professional | | $1,659.59 | $2,290.87 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $9,549.93
| Facility | | $1,737.80 | $2,344.23 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,570.40 / $5,248.07
| Professional | | $2,290.87 | $2,570.40 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $20,892.96
| Facility | | $3,311.31 | $3,311.31 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $7,413.10
| Professional | | $2,398.83 | $2,398.83 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,951.21 / $5,248.07
| Facility | | $1,905.46 | $2,951.21 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $3,235.94
| Professional | | $1,584.89 | $2,089.30 | $3,235.94 |