- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.07 / $2,294.03 / $7,891.25
| Facility | | $1,857.07 | $2,294.03 | $7,891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.06 / $1,857.07 / $2,184.79
| Professional | | $1,857.06 | $1,857.07 | $2,184.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.87 / $2,457.89 / $4,791.97
| Facility | | $719.87 | $2,457.89 | $4,791.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,184.79 / $2,184.79 / $2,184.79
| Professional | | $2,184.79 | $2,184.79 | $2,184.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Facility | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Professional | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.87 / $2,075.55 / $9,193.40
| Facility | | $719.87 | $2,075.55 | $9,193.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.28 / $2,123.77 / $2,267.96
| Professional | | $1,875.28 | $2,123.77 | $2,267.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.28 / $2,123.77 / $2,269.09
| Professional | | $1,875.28 | $2,123.77 | $2,269.09 |