- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $5,888.44
| Professional | | $2,041.74 | $2,398.83 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,365.16 / $7,943.28
| Facility | | $1,659.59 | $4,365.16 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,884.03 / $4,677.35
| Professional | | $2,238.72 | $2,884.03 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $4,570.88
| Professional | | $1,905.46 | $2,570.40 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,511.89 / $5,011.87
| Facility | | $1,905.46 | $2,511.89 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,818.38 / $15,848.93
| Professional | | $1,995.26 | $2,818.38 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,089.30 / $5,248.07
| Facility | | $831.76 | $2,089.30 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $4,265.80
| Professional | | $1,949.84 | $2,398.83 | $4,265.80 |