- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,897.79 / $4,897.79
| Facility | | $3,019.95 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,511.89 / $3,981.07
| Professional | | $2,137.96 | $2,511.89 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $3,467.37 / $3,467.37
| Facility | | $691.83 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,467.37 / $3,467.37
| Professional | | $2,041.74 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,951.21 / $6,309.57
| Professional | | $2,137.96 | $2,951.21 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,897.79 / $7,079.46
| Facility | | $2,398.83 | $4,897.79 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $3,467.37
| Professional | | $2,187.76 | $2,570.40 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,691.53 / $5,128.61
| Professional | | $1,949.84 | $2,691.53 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $3,548.13 / $6,025.60
| Facility | | $691.83 | $3,548.13 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,818.38 / $3,890.45
| Professional | | $2,137.96 | $2,818.38 | $3,890.45 |