- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,290.87 / $8,511.38
| Facility | | $2,187.76 | $2,290.87 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,238.72 / $5,623.41
| Professional | | $2,041.74 | $2,238.72 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,248.07 / $6,309.57
| Professional | | $4,265.80 | $5,248.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,168.69 / $6,918.31
| Professional | | $2,290.87 | $4,168.69 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,951.21 / $4,168.69
| Facility | | $2,290.87 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,801.89 / $16,982.44
| Professional | | $2,137.96 | $3,801.89 | $16,982.44 |
- 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
- $2,041.74 / $3,981.07 / $5,623.41
| Professional | | $2,041.74 | $3,981.07 | $5,623.41 |