- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,886.26 / $2,895.96 / $3,861.28
| Facility | | $1,886.26 | $2,895.96 | $3,861.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,886.26 / $1,908.45 / $2,152.56
| Professional | | $1,886.26 | $1,908.45 | $2,152.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.20 / $1,549.20 / $4,089.09
| Professional | | $1,549.20 | $1,549.20 | $4,089.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,132.96 / $4,654.72 / $5,289.39
| Facility | | $3,132.96 | $4,654.72 | $5,289.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,575.36 / $3,187.33
| Professional | | $2,549.86 | $2,575.36 | $3,187.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,331.48 / $2,884.87 / $10,540.87
| Facility | | $1,331.48 | $2,884.87 | $10,540.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,331.48 / $2,507.62
| Professional | | $932.03 | $1,331.48 | $2,507.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,331.48 / $2,662.96
| Professional | | $932.03 | $1,331.48 | $2,662.96 |