- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,754.23 / $5,623.41
| Facility | | $1,995.26 | $2,754.23 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,754.23 / $4,786.30
| Professional | | $1,949.84 | $2,754.23 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,818.38 / $11,220.18
| Facility | | $2,089.30 | $2,818.38 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,884.03 / $5,888.44
| Professional | | $2,754.23 | $2,884.03 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $21,877.62
| Facility | | $2,884.03 | $2,884.03 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $8,317.64
| Professional | | $2,089.30 | $2,089.30 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,467.37 / $6,165.95
| Facility | | $3,019.95 | $3,467.37 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $3,801.89
| Professional | | $1,862.09 | $2,454.71 | $3,801.89 |