- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $9,549.93
| Facility | | $1,819.70 | $2,041.74 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,454.71
| Professional | | $1,862.09 | $1,862.09 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $2,089.30 / $4,265.80
| Facility | | $707.95 | $2,089.30 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,819.70 / $2,187.76
| Professional | | $1,318.26 | $1,819.70 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $4,365.16
| Facility | | $2,041.74 | $2,041.74 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,290.87
| Professional | | $1,819.70 | $2,041.74 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $724.44 / $2,818.38
| Facility | | $436.52 | $724.44 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,137.96 / $2,238.72
| Professional | | $1,862.09 | $2,137.96 | $2,238.72 |