- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,757.15 / $1,957.96 / $11,904.40
| Facility | | $1,757.15 | $1,957.96 | $11,904.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,957.96 / $1,957.96 / $2,183.88
| Professional | | $1,957.96 | $1,957.96 | $2,183.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,585.51 / $2,635.73 / $17,171.00
| Facility | | $2,585.51 | $2,635.73 | $17,171.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,510.21 / $3,432.71
| Professional | | $2,510.21 | $2,510.21 | $3,432.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,562.07 / $6,183.92 / $14,312.75
| Facility | | $4,562.07 | $6,183.92 | $14,312.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.71 / $1,478.00 / $2,963.23
| Professional | | $1,139.71 | $1,478.00 | $2,963.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,957.96 / $3,099.02 / $3,904.77
| Facility | | $1,957.96 | $3,099.02 | $3,904.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.62 / $1,380.62 / $1,380.62
| Professional | | $1,380.62 | $1,380.62 | $1,380.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,549.51 / $2,634.17
| Professional | | $1,054.29 | $1,549.51 | $2,634.17 |