- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,949.84 / $8,511.38
| Facility | | $1,905.46 | $1,949.84 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,949.84 / $3,162.28
| Professional | | $1,258.93 | $1,949.84 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,073.80 / $4,897.79
| Professional | | $3,311.31 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $5,370.32
| Professional | | $2,570.40 | $3,311.31 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $5,623.41
| Facility | | $1,905.46 | $2,570.40 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,467.37 / $4,466.84
| Professional | | $2,041.74 | $3,467.37 | $4,466.84 |
- 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
- $2,089.30 / $3,548.13 / $4,786.30
| Professional | | $2,089.30 | $3,548.13 | $4,786.30 |