- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,187.76 / $9,549.93
| Facility | | $2,137.96 | $2,187.76 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $5,370.32
| Professional | | $1,621.81 | $2,137.96 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $6,025.60
| Professional | | $4,168.69 | $5,128.61 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,073.80 / $6,606.93
| Professional | | $1,905.46 | $4,073.80 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,090.30 / $3,715.35
| Facility | | $2,187.76 | $3,090.30 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,801.89 / $5,623.41
| Professional | | $2,089.30 | $3,801.89 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $33,884.42
| Facility | | $1,819.70 | $2,041.74 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,890.45 / $5,495.41
| Professional | | $1,995.26 | $3,890.45 | $5,495.41 |