- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,238.72 / $8,511.38
| Facility | | $2,137.96 | $2,238.72 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $5,888.44
| Professional | | $1,995.26 | $2,238.72 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $6,165.95
| Professional | | $4,168.69 | $5,128.61 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,073.80 / $6,760.83
| Professional | | $2,290.87 | $4,073.80 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,884.03 / $4,168.69
| Facility | | $2,238.72 | $2,884.03 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,981.07 / $16,595.87
| Professional | | $2,137.96 | $3,981.07 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,981.07 / $5,495.41
| Professional | | $2,137.96 | $3,981.07 | $5,495.41 |