- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,157.57 / $3,978.80 / $6,049.26
| Facility | | $2,157.57 | $3,978.80 | $6,049.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,218.07 / $6,049.88
| Professional | | $2,016.42 | $2,218.07 | $6,049.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,677.26 / $6,832.93 / $10,973.50
| Facility | | $1,677.26 | $6,832.93 | $10,973.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.40 / $1,913.30 / $12,826.83
| Professional | | $1,315.40 | $1,913.30 | $12,826.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.29 / $2,016.42 / $2,016.42
| Facility | | $1,902.29 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,970.45 / $2,391.63 / $3,109.12
| Facility | | $1,970.45 | $2,391.63 | $3,109.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,976.55 / $1,976.55 / $1,976.55
| Professional | | $1,976.55 | $1,976.55 | $1,976.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Facility | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |