- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,937.15 / $3,063.71 / $5,287.28
| Facility | | $1,937.15 | $3,063.71 | $5,287.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.15 / $1,937.15 / $1,937.15
| Professional | | $1,937.15 | $1,937.15 | $1,937.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.29 / $2,034.00 / $4,036.46
| Professional | | $1,162.29 | $2,034.00 | $4,036.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,138.98 / $4,401.09 / $5,432.11
| Facility | | $3,138.98 | $4,401.09 | $5,432.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.02 / $2,645.02 / $2,645.02
| Professional | | $2,645.02 | $2,645.02 | $2,645.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,937.15 / $2,734.80 / $10,825.25
| Facility | | $1,937.15 | $2,734.80 | $10,825.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.18 / $1,367.40 / $11,349.42
| Professional | | $957.18 | $1,367.40 | $11,349.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.18 / $1,367.40 / $2,577.55
| Professional | | $957.18 | $1,367.40 | $2,577.55 |