- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,137.96 / $8,511.38
| Facility | | $1,949.84 | $2,137.96 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $4,168.69
| Professional | | $1,949.84 | $2,290.87 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,570.88 / $5,370.32
| Professional | | $3,801.89 | $4,570.88 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,890.45 / $6,025.60
| Professional | | $2,344.23 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,951.21 / $4,677.35
| Facility | | $1,905.46 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,467.37 / $15,488.17
| Professional | | $1,949.84 | $3,467.37 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,819.70 / $2,041.74
| Facility | | $676.08 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,884.03 / $4,570.88
| Professional | | $1,819.70 | $2,884.03 | $4,570.88 |