- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,791.13 / $2,649.39 / $2,734.23
| Facility | | $1,791.13 | $2,649.39 | $2,734.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,791.13 / $2,052.34 / $3,731.53
| Professional | | $1,791.13 | $2,052.34 | $3,731.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,920.44 / $4,116.46 / $18,096.75
| Facility | | $3,920.44 | $4,116.46 | $18,096.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,966.59 / $2,000.39 / $3,171.80
| Professional | | $1,966.59 | $2,000.39 | $3,171.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,694.60 / $2,694.60 / $2,694.60
| Facility | | $2,694.60 | $2,694.60 | $2,694.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.06 / $1,967.06 / $1,967.06
| Professional | | $1,967.06 | $1,967.06 | $1,967.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,791.13 / $3,159.55 / $17,419.57
| Facility | | $1,791.13 | $3,159.55 | $17,419.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.29 / $2,095.62 / $3,488.45
| Professional | | $1,361.29 | $2,095.62 | $3,488.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.29 / $1,955.86 / $2,834.32
| Professional | | $1,361.29 | $1,955.86 | $2,834.32 |