- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,188.44 / $3,461.17 / $5,973.19
| Facility | | $2,188.44 | $3,461.17 | $5,973.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,956.73 / $2,188.44 / $2,497.41
| Professional | | $1,956.73 | $2,188.44 | $2,497.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.14 / $4,442.05 / $4,800.00
| Professional | | $2,495.14 | $4,442.05 | $4,800.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,546.19 / $4,972.03 / $6,136.80
| Facility | | $3,546.19 | $4,972.03 | $6,136.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,987.90 / $2,987.90 / $2,987.90
| Professional | | $2,987.90 | $2,987.90 | $2,987.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,188.44 / $3,089.58 / $12,229.59
| Facility | | $2,188.44 | $3,089.58 | $12,229.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,544.79 / $12,821.76
| Professional | | $1,081.34 | $1,544.79 | $12,821.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,544.79 / $2,911.93
| Professional | | $1,081.34 | $1,544.79 | $2,911.93 |