- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $3,890.45
| Facility | | $1,905.46 | $2,290.87 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $3,715.35
| Professional | | $1,905.46 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,019.95 / $8,912.51
| Facility | | $2,238.72 | $3,019.95 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $5,495.41
| Professional | | $2,344.23 | $3,162.28 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $16,595.87
| Facility | | $3,090.30 | $3,090.30 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $6,456.54
| Professional | | $2,238.72 | $2,238.72 | $6,456.54 |
- 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 / $2,187.76 / $3,388.44
| Professional | | $1,659.59 | $2,187.76 | $3,388.44 |