- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $4,570.88
| Facility | | $1,819.70 | $2,398.83 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $3,801.89
| Professional | | $1,819.70 | $2,398.83 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,630.27 / $8,709.64
| Facility | | $1,905.46 | $2,630.27 | $8,709.64 |
- 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
- $2,754.23 / $2,754.23 / $18,620.87
| Facility | | $2,754.23 | $2,754.23 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $6,606.93
| Professional | | $1,995.26 | $1,995.26 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,235.94 / $5,754.40
| Facility | | $2,089.30 | $3,235.94 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $3,467.37
| Professional | | $1,659.59 | $2,238.72 | $3,467.37 |