- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,175.41 / $2,262.42 / $2,262.42
| Facility | | $2,175.41 | $2,262.42 | $2,262.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.35 / $2,219.94 / $2,423.34
| Professional | | $1,980.35 | $2,219.94 | $2,423.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,845.49 / $4,571.07 / $4,804.18
| Facility | | $2,845.49 | $4,571.07 | $4,804.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.15 / $2,439.35 / $2,731.58
| Professional | | $1,661.15 | $2,439.35 | $2,731.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,428.30 / $6,365.04 / $7,321.91
| Facility | | $3,428.30 | $6,365.04 | $7,321.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,342.52 / $5,683.08 / $7,542.27
| Professional | | $4,342.52 | $5,683.08 | $7,542.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $5,356.73
| Facility | | $2,941.06 | $2,941.06 | $5,356.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,538.78 / $21,804.91
| Professional | | $2,146.96 | $2,538.78 | $21,804.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.98 / $2,867.06 / $3,583.82
| Professional | | $2,350.98 | $2,867.06 | $3,583.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.30 / $2,280.46 / $3,122.37
| Professional | | $1,520.30 | $2,280.46 | $3,122.37 |