- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,630.27 / $4,466.84
| Facility | | $1,995.26 | $2,630.27 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $4,466.84
| Professional | | $1,949.84 | $2,630.27 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $10,964.78
| Facility | | $2,041.74 | $2,754.23 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,754.23 / $6,025.60
| Professional | | $2,691.53 | $2,754.23 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $19,952.62
| Facility | | $3,801.89 | $3,801.89 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $7,762.47
| Professional | | $2,754.23 | $2,754.23 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,388.44 / $6,025.60
| Facility | | $2,691.53 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,511.89 / $3,801.89
| Professional | | $1,862.09 | $2,511.89 | $3,801.89 |