- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,884.03 / $10,964.78
| Professional | | $2,290.87 | $2,884.03 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $5,370.32 / $7,943.28
| Facility | | $1,659.59 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,162.28 / $5,888.44
| Professional | | $2,691.53 | $3,162.28 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,019.95 / $5,248.07
| Professional | | $2,238.72 | $3,019.95 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,951.21 / $5,248.07
| Facility | | $1,949.84 | $2,951.21 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,090.30 / $18,620.87
| Professional | | $2,238.72 | $3,090.30 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,290.87 / $5,495.41
| Facility | | $1,380.38 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,754.23 / $4,786.30
| Professional | | $2,187.76 | $2,754.23 | $4,786.30 |