- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,187.76 / $8,511.38
| Facility | | $1,995.26 | $2,187.76 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $4,466.84
| Professional | | $1,995.26 | $2,398.83 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,786.30 / $5,754.40
| Professional | | $4,073.80 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,981.07 / $6,025.60
| Professional | | $2,454.71 | $3,981.07 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,019.95 / $5,011.87
| Facility | | $2,187.76 | $3,019.95 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,715.35 / $15,848.93
| Professional | | $1,995.26 | $3,715.35 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,819.70 / $2,041.74
| Facility | | $676.08 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,162.28 / $4,786.30
| Professional | | $1,995.26 | $3,162.28 | $4,786.30 |