- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,459.17 / $2,158.35 / $2,227.46
| Facility | | $1,459.17 | $2,158.35 | $2,227.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.17 / $1,671.96 / $3,039.93
| Professional | | $1,459.17 | $1,671.96 | $3,039.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,193.83 / $3,353.52 / $14,742.72
| Facility | | $3,193.83 | $3,353.52 | $14,742.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.35 / $1,619.41 / $2,585.13
| Professional | | $1,609.35 | $1,619.41 | $2,585.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,283.76
| Facility | | $2,283.76 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $1,667.14 / $2,434.60
| Professional | | $1,667.14 | $1,667.14 | $2,434.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,459.17 / $2,674.62 / $14,087.74
| Facility | | $1,459.17 | $2,674.62 | $14,087.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.00 / $1,707.22 / $2,688.98
| Professional | | $1,114.00 | $1,707.22 | $2,688.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.00 / $1,593.36 / $2,261.71
| Professional | | $1,114.00 | $1,593.36 | $2,261.71 |