- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $3,801.89
| Facility | | $1,862.09 | $2,187.76 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,238.72 / $3,715.35
| Professional | | $1,862.09 | $2,238.72 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $8,912.51
| Facility | | $1,819.70 | $2,454.71 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,454.71 / $5,011.87
| Professional | | $2,290.87 | $2,454.71 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $16,595.87
| Facility | | $2,754.23 | $2,754.23 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $6,309.57
| Professional | | $1,995.26 | $1,995.26 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $5,370.32
| Facility | | $2,187.76 | $2,951.21 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $3,311.31
| Professional | | $1,659.59 | $2,187.76 | $3,311.31 |