- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,630.78 / $10,232.93
| Facility | | $2,290.87 | $3,630.78 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,818.38 / $3,467.37
| Professional | | $2,754.23 | $2,818.38 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,630.78 / $6,760.83
| Facility | | $2,818.38 | $3,630.78 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $2,884.03 / $3,630.78
| Professional | | $141.25 | $2,884.03 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,090.30
| Facility | | $2,884.03 | $2,884.03 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,548.13
| Professional | | $2,884.03 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,187.76 / $3,715.35
| Facility | | $1,819.70 | $2,187.76 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,467.37
| Professional | | $2,884.03 | $2,884.03 | $3,467.37 |