- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,626.33 / $2,405.61 / $2,482.65
| Facility | | $1,626.33 | $2,405.61 | $2,482.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.33 / $1,897.34 / $3,388.19
| Professional | | $1,626.33 | $1,897.34 | $3,388.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,559.71 / $3,737.70 / $16,431.62
| Facility | | $3,559.71 | $3,737.70 | $16,431.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.13 / $1,898.20 / $2,879.96
| Professional | | $1,866.13 | $1,898.20 | $2,879.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,479.82 / $2,479.82 / $2,479.82
| Facility | | $2,479.82 | $2,479.82 | $2,479.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.27 / $1,810.27 / $2,554.21
| Professional | | $1,810.27 | $1,810.27 | $2,554.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,626.33 / $2,868.84 / $16,444.91
| Facility | | $1,626.33 | $2,868.84 | $16,444.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.74 / $1,912.47 / $3,314.22
| Professional | | $1,291.74 | $1,912.47 | $3,314.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.74 / $1,789.40 / $2,821.55
| Professional | | $1,291.74 | $1,789.40 | $2,821.55 |