- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,454.71 / $4,265.80
| Facility | | $1,778.28 | $2,454.71 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,454.71 / $4,168.69
| Professional | | $1,778.28 | $2,454.71 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,090.30 / $9,549.93
| Facility | | $2,290.87 | $3,090.30 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,019.95 / $5,754.40
| Professional | | $2,754.23 | $3,019.95 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $20,892.96
| Facility | | $3,019.95 | $3,019.95 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $7,413.10
| Professional | | $2,187.76 | $2,187.76 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,019.95 / $5,370.32
| Facility | | $1,949.84 | $3,019.95 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,344.23 / $3,467.37
| Professional | | $1,659.59 | $2,344.23 | $3,467.37 |