- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $4,466.84
| Facility | | $1,778.28 | $2,344.23 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $3,715.35
| Professional | | $1,778.28 | $2,344.23 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $8,511.38
| Facility | | $1,905.46 | $2,570.40 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,630.27 / $5,248.07
| Professional | | $2,290.87 | $2,630.27 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $18,197.01
| Facility | | $3,162.28 | $3,162.28 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $6,456.54
| Professional | | $2,290.87 | $2,290.87 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,162.28 / $5,623.41
| Facility | | $2,041.74 | $3,162.28 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,187.76 / $3,467.37
| Professional | | $1,621.81 | $2,187.76 | $3,467.37 |