- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $8,511.38
| Facility | | $1,995.26 | $1,995.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,995.26 / $4,677.35
| Professional | | $1,659.59 | $1,995.26 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,677.35 / $5,495.41
| Professional | | $3,890.45 | $4,677.35 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,715.35 / $6,025.60
| Professional | | $1,862.09 | $3,715.35 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,630.27 / $5,888.44
| Facility | | $1,995.26 | $2,630.27 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,548.13 / $15,135.61
| Professional | | $1,949.84 | $3,548.13 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $11,481.54
| Facility | | $1,819.70 | $2,041.74 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,630.78 / $5,011.87
| Professional | | $1,949.84 | $3,630.78 | $5,011.87 |