- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,802.25 / $2,008.23 / $12,210.00
| Facility | | $1,802.25 | $2,008.23 | $12,210.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,008.23 / $2,008.23 / $2,239.94
| Professional | | $2,008.23 | $2,008.23 | $2,239.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,750.16 / $1,750.16 / $1,750.16
| Facility | | $1,750.16 | $1,750.16 | $1,750.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,703.38 / $3,553.02
| Professional | | $2,574.65 | $2,703.38 | $3,553.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,679.16 / $6,342.64 / $14,680.12
| Facility | | $4,679.16 | $6,342.64 | $14,680.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,008.23 / $2,574.65 / $3,253.33
| Facility | | $2,008.23 | $2,574.65 | $3,253.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,468.53 / $2,574.65
| Professional | | $1,081.34 | $1,468.53 | $2,574.65 |