- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,671.43 / $2,472.33 / $2,551.52
| Facility | | $1,671.43 | $2,472.33 | $2,551.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.43 / $2,018.19 / $3,482.15
| Professional | | $1,671.43 | $2,018.19 | $3,482.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,658.43 / $3,841.35 / $16,887.31
| Facility | | $3,658.43 | $3,841.35 | $16,887.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.05 / $2,025.27 / $2,959.83
| Professional | | $1,991.05 | $2,025.27 | $2,959.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $2,637.76 / $2,637.76
| Facility | | $2,637.76 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $1,925.56 / $2,716.89
| Professional | | $1,925.56 | $1,925.56 | $2,716.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,671.43 / $2,948.42 / $17,548.22
| Facility | | $1,671.43 | $2,948.42 | $17,548.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.22 / $1,977.25 / $3,536.09
| Professional | | $1,378.22 | $1,977.25 | $3,536.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.22 / $1,825.15 / $2,705.63
| Professional | | $1,378.22 | $1,825.15 | $2,705.63 |