- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,187.76 / $8,511.38
| Facility | | $1,949.84 | $2,187.76 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,187.76 / $7,762.47
| Professional | | $1,096.48 | $2,187.76 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,388.44 / $4,073.80
| Professional | | $2,951.21 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,918.31 / $11,220.18
| Professional | | $5,370.32 | $6,918.31 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,238.72 / $5,888.44
| Facility | | $1,949.84 | $2,238.72 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,162.28 / $5,011.87
| Professional | | $1,621.81 | $3,162.28 | $5,011.87 |
- 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
- $1,621.81 / $3,019.95 / $5,011.87
| Professional | | $1,621.81 | $3,019.95 | $5,011.87 |