- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,553.39 / $1,730.92 / $10,524.00
| Facility | | $1,553.39 | $1,730.92 | $10,524.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.92 / $1,775.30 / $1,930.64
| Professional | | $1,730.92 | $1,775.30 | $1,930.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.13 / $2,219.13 / $3,034.66
| Professional | | $2,219.13 | $2,219.13 | $3,034.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,478.70 / $5,466.81 / $12,653.00
| Facility | | $1,478.70 | $5,466.81 | $12,653.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,549.86 / $3,187.33
| Professional | | $2,549.86 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,553.39 / $1,775.30 / $2,374.46
| Facility | | $1,553.39 | $1,775.30 | $2,374.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.13 / $2,219.13 / $2,219.13
| Professional | | $2,219.13 | $2,219.13 | $2,219.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,331.48 / $2,662.96
| Professional | | $932.03 | $1,331.48 | $2,662.96 |