- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $8,511.38
| Facility | | $2,089.30 | $2,187.76 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $3,388.44
| Professional | | $1,380.38 | $2,187.76 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,466.84 / $5,370.32
| Professional | | $3,715.35 | $4,466.84 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,630.78 / $6,025.60
| Professional | | $2,884.03 | $3,630.78 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,884.03 / $6,165.95
| Facility | | $2,089.30 | $2,884.03 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,801.89 / $4,786.30
| Professional | | $1,445.44 | $3,801.89 | $4,786.30 |
- 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
- $1,445.44 / $3,890.45 / $5,128.61
| Professional | | $1,445.44 | $3,890.45 | $5,128.61 |