- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,845.43 / $2,729.70 / $2,817.13
| Facility | | $1,845.43 | $2,729.70 | $2,817.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.43 / $2,114.56 / $3,844.65
| Professional | | $1,845.43 | $2,114.56 | $3,844.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,039.28 / $4,241.24 / $18,645.32
| Facility | | $4,039.28 | $4,241.24 | $18,645.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,009.72 / $2,207.84 / $3,269.48
| Professional | | $2,009.72 | $2,207.84 | $3,269.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.71 / $2,282.71 / $2,282.71
| Facility | | $2,282.71 | $2,282.71 | $2,282.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.39 / $1,666.39 / $1,666.39
| Professional | | $1,666.39 | $1,666.39 | $1,666.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,845.43 / $3,255.35 / $19,065.24
| Facility | | $1,845.43 | $3,255.35 | $19,065.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.78 / $2,159.16 / $3,589.58
| Professional | | $1,518.78 | $2,159.16 | $3,589.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.23 / $1,982.23 / $1,982.23
| Facility | | $1,982.23 | $1,982.23 | $1,982.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.78 / $2,015.15 / $2,860.42
| Professional | | $1,518.78 | $2,015.15 | $2,860.42 |