- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,311.31 / $6,456.54
| Facility | | $2,089.30 | $3,311.31 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,137.96 / $2,570.40
| Professional | | $2,089.30 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,691.53 / $5,623.41
| Facility | | $794.33 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $2,137.96 / $3,235.94
| Professional | | $724.44 | $2,137.96 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,187.76 / $2,187.76
| Facility | | $2,137.96 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $794.33 / $2,187.76
| Professional | | $630.96 | $794.33 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $4,466.84
| Facility | | $2,187.76 | $2,187.76 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $2,884.03
| Professional | | $2,137.96 | $2,290.87 | $2,884.03 |