- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $3,548.13
| Facility | | $1,698.24 | $2,089.30 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $3,388.44
| Professional | | $1,698.24 | $2,089.30 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $8,317.64
| Facility | | $1,659.59 | $2,238.72 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,290.87 / $4,677.35
| Professional | | $2,089.30 | $2,290.87 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $15,848.93
| Facility | | $3,235.94 | $3,235.94 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $5,888.44
| Professional | | $2,754.23 | $2,754.23 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,398.83 / $4,168.69
| Facility | | $954.99 | $2,398.83 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $3,090.30
| Professional | | $1,513.56 | $2,041.74 | $3,090.30 |