- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $5,495.41
| Facility | | $1,949.84 | $2,398.83 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,511.89 / $3,890.45
| Professional | | $1,905.46 | $2,511.89 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $9,772.37
| Facility | | $2,041.74 | $2,754.23 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $5,623.41
| Professional | | $2,398.83 | $2,754.23 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $17,378.01
| Facility | | $2,754.23 | $2,754.23 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $6,606.93
| Professional | | $2,041.74 | $2,041.74 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,311.31 / $6,025.60
| Facility | | $2,454.71 | $3,311.31 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $3,715.35
| Professional | | $1,862.09 | $2,344.23 | $3,715.35 |