- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,691.53 / $4,570.88
| Facility | | $1,862.09 | $2,691.53 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $4,466.84
| Professional | | $1,862.09 | $2,630.27 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $10,471.29
| Facility | | $1,995.26 | $2,691.53 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $5,888.44
| Professional | | $2,630.27 | $2,754.23 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $20,417.38
| Facility | | $3,548.13 | $3,548.13 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $7,943.28
| Professional | | $2,570.40 | $2,570.40 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,311.31 / $5,888.44
| Facility | | $2,344.23 | $3,311.31 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,570.40 / $3,981.07
| Professional | | $1,819.70 | $2,570.40 | $3,981.07 |