- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.47 / $2,066.26 / $3,565.89
| Facility | | $1,306.47 | $2,066.26 | $3,565.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.47 / $1,337.21 / $1,490.91
| Professional | | $1,306.47 | $1,337.21 | $1,490.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.79 / $1,371.78 / $2,722.31
| Professional | | $514.79 | $1,371.78 | $2,722.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,117.01 / $2,968.21 / $3,663.55
| Facility | | $2,117.01 | $2,968.21 | $3,663.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.07 / $1,784.07 / $1,784.07
| Professional | | $1,784.07 | $1,784.07 | $1,784.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.47 / $1,844.42 / $7,300.85
| Facility | | $1,306.47 | $1,844.42 | $7,300.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $922.21 / $7,654.36
| Professional | | $645.54 | $922.21 | $7,654.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,537.02 / $1,537.02 / $1,844.42
| Facility | | $1,537.02 | $1,537.02 | $1,844.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $922.21 / $1,844.42
| Professional | | $645.54 | $922.21 | $1,844.42 |