- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,137.96 / $8,511.38
| Facility | | $2,089.30 | $2,137.96 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $4,897.79
| Professional | | $1,737.80 | $2,089.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,570.88 / $5,495.41
| Professional | | $3,715.35 | $4,570.88 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,890.45 / $6,456.54
| Professional | | $2,290.87 | $3,890.45 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,754.23 / $4,265.80
| Facility | | $2,137.96 | $2,754.23 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,548.13 / $19,952.62
| Professional | | $2,137.96 | $3,548.13 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $11,481.54
| Facility | | $1,819.70 | $2,041.74 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,548.13 / $5,128.61
| Professional | | $2,137.96 | $3,548.13 | $5,128.61 |