- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,238.72 / $8,511.38
| Facility | | $2,041.74 | $2,238.72 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,511.89 / $4,677.35
| Professional | | $2,041.74 | $2,511.89 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,011.87 / $5,888.44
| Professional | | $4,073.80 | $5,011.87 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,073.80 / $6,309.57
| Professional | | $2,398.83 | $4,073.80 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,090.30 / $4,897.79
| Facility | | $2,238.72 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,715.35 / $16,595.87
| Professional | | $2,089.30 | $3,715.35 | $16,595.87 |
- 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
- $2,041.74 / $3,162.28 / $4,897.79
| Professional | | $2,041.74 | $3,162.28 | $4,897.79 |