- 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
- $1,778.28 / $2,137.96 / $5,128.61
| Professional | | $1,778.28 | $2,137.96 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $5,370.32 / $7,943.28
| Facility | | $1,659.59 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,737.80 / $5,011.87
| Professional | | $1,548.82 | $1,737.80 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $3,981.07
| Professional | | $1,778.28 | $2,344.23 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $5,128.61
| Facility | | $1,698.24 | $2,238.72 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $24,547.09
| Professional | | $1,698.24 | $2,238.72 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,290.87 / $5,495.41
| Facility | | $1,348.96 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $3,715.35
| Professional | | $1,698.24 | $2,041.74 | $3,715.35 |