- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,772.73 / $5,182.68 / $7,774.02
| Facility | | $2,772.73 | $5,182.68 | $7,774.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.98 / $2,098.98 / $2,518.79
| Professional | | $2,098.98 | $2,098.98 | $2,518.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,029.02 / $7,704.92 / $12,206.79
| Facility | | $2,029.02 | $7,704.92 | $12,206.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.24 / $2,073.07 / $13,736.69
| Professional | | $1,425.24 | $2,073.07 | $13,736.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,202.64
| Facility | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,202.64
| Professional | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,098.98 / $2,518.79 / $3,001.56
| Facility | | $2,098.98 | $2,518.79 | $3,001.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $2,159.44
| Professional | | $2,159.44 | $2,159.44 | $2,159.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $2,159.44
| Professional | | $2,159.44 | $2,159.44 | $2,159.44 |