- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,089.30 / $8,511.38
| Facility | | $1,949.84 | $2,089.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $4,897.79
| Professional | | $1,548.82 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,630.78 / $4,365.16
| Professional | | $3,090.30 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $5,623.41
| Professional | | $2,089.30 | $3,388.44 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,454.71 / $3,548.13
| Facility | | $2,089.30 | $2,454.71 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,630.78 / $5,495.41
| Professional | | $1,659.59 | $3,630.78 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $3,090.30
| Facility | | $1,819.70 | $2,041.74 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,630.78 / $4,786.30
| Professional | | $1,905.46 | $3,630.78 | $4,786.30 |