- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,715.35 / $7,943.28
| Facility | | $2,041.74 | $3,715.35 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $4,677.35
| Professional | | $1,659.59 | $1,949.84 | $4,677.35 |
- 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
- $1,819.70 / $2,344.23 / $3,801.89
| Professional | | $1,819.70 | $2,344.23 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,137.96 / $3,801.89
| Professional | | $1,479.11 | $2,137.96 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,089.30 / $4,265.80
| Facility | | $1,659.59 | $2,089.30 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $13,489.63
| Professional | | $1,621.81 | $2,290.87 | $13,489.63 |
- 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
- $1,584.89 / $1,949.84 / $3,467.37
| Professional | | $1,584.89 | $1,949.84 | $3,467.37 |