- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,862.09 / $8,511.38
| Facility | | $1,778.28 | $1,862.09 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,862.09 / $3,019.95
| Professional | | $1,202.26 | $1,862.09 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,981.07 / $4,677.35
| Professional | | $3,235.94 | $3,981.07 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,162.28 / $5,248.07
| Professional | | $2,511.89 | $3,162.28 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,454.71 / $5,370.32
| Facility | | $1,778.28 | $2,454.71 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,467.37 / $4,168.69
| Professional | | $1,862.09 | $3,467.37 | $4,168.69 |
- 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
- $1,862.09 / $3,388.44 / $4,466.84
| Professional | | $1,862.09 | $3,388.44 | $4,466.84 |