- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,398.83 / $4,073.80
| Facility | | $2,238.72 | $2,398.83 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,344.23 / $2,818.38
| Professional | | $2,238.72 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,905.46 / $4,786.30
| Facility | | $1,479.11 | $1,905.46 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $2,818.38
| Professional | | $1,479.11 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,479.11 / $2,884.03
| Facility | | $1,412.54 | $1,479.11 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,905.46
| Professional | | $1,479.11 | $1,479.11 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,137.96 / $4,677.35
| Facility | | $1,479.11 | $2,137.96 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,818.38 / $2,818.38
| Professional | | $1,698.24 | $2,818.38 | $2,818.38 |