- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,041.74 / $8,511.38
| Facility | | $1,995.26 | $2,041.74 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,041.74 / $3,311.31
| Professional | | $1,412.54 | $2,041.74 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $5,128.61
| Professional | | $3,548.13 | $4,365.16 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $5,754.40
| Professional | | $2,754.23 | $3,388.44 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $6,025.60
| Facility | | $1,995.26 | $2,691.53 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,630.78 / $4,677.35
| Professional | | $2,041.74 | $3,630.78 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,715.35 / $5,011.87
| Professional | | $2,041.74 | $3,715.35 | $5,011.87 |