- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,949.84 / $2,344.23
| Facility | | $1,513.56 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,290.87 / $2,691.53
| Professional | | $1,513.56 | $2,290.87 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,715.35 / $5,370.32
| Facility | | $794.33 | $3,715.35 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $2,818.38 / $4,168.69
| Professional | | $302.00 | $2,818.38 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $2,630.27
| Facility | | $1,318.26 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,235.94 / $3,235.94
| Professional | | $2,238.72 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $331.13 / $3,311.31
| Professional | | $257.04 | $331.13 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $1,122.02 / $2,290.87
| Facility | | $158.49 | $1,122.02 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $2,238.72
| Professional | | $1,148.15 | $1,621.81 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |