- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $3,630.78
| Facility | | $2,290.87 | $3,162.28 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $2,187.76
| Professional | | $1,258.93 | $1,621.81 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,348.96 / $3,162.28
| Professional | | $1,148.15 | $1,348.96 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,630.78 / $4,570.88
| Facility | | $2,454.71 | $3,630.78 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,290.87 / $8,912.51
| Facility | | $1,659.59 | $2,290.87 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $9,549.93
| Professional | | $794.33 | $1,148.15 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,905.46 / $2,290.87
| Facility | | $794.33 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $2,089.30
| Professional | | $794.33 | $1,148.15 | $2,089.30 |