- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $5,370.32
| Facility | | $2,089.30 | $2,089.30 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $2,818.38
| Professional | | $1,513.56 | $1,995.26 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,754.40 / $6,760.83
| Professional | | $3,981.07 | $5,754.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $4,265.80
| Professional | | $3,467.37 | $3,467.37 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,089.30 / $5,370.32
| Facility | | $1,513.56 | $2,089.30 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,548.13 / $6,025.60
| Professional | | $1,258.93 | $3,548.13 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,090.30 / $5,128.61
| Professional | | $1,258.93 | $3,090.30 | $5,128.61 |