- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,636.10 / $2,420.06 / $2,497.56
| Facility | | $1,636.10 | $2,420.06 | $2,497.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.84 / $1,874.70 / $3,408.54
| Professional | | $1,455.84 | $1,874.70 | $3,408.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,581.09 / $3,760.14 / $16,530.31
| Facility | | $3,581.09 | $3,760.14 | $16,530.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.54 / $1,788.71 / $2,897.26
| Professional | | $1,747.54 | $1,788.71 | $2,897.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.78 / $1,902.78 / $1,902.78
| Facility | | $1,902.78 | $1,902.78 | $1,902.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.03 / $1,389.03 / $1,959.86
| Professional | | $1,389.03 | $1,389.03 | $1,959.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,636.10 / $2,886.07 / $15,444.00
| Facility | | $1,636.10 | $2,886.07 | $15,444.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.88 / $1,914.24 / $3,124.87
| Professional | | $1,222.88 | $1,914.24 | $3,124.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.04 / $1,786.57 / $2,392.80
| Professional | | $1,191.04 | $1,786.57 | $2,392.80 |