- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,089.30 / $8,511.38
| Facility | | $1,905.46 | $2,089.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $4,265.80
| Professional | | $1,905.46 | $2,290.87 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,570.88 / $5,495.41
| Professional | | $3,890.45 | $4,570.88 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,801.89 / $5,754.40
| Professional | | $2,187.76 | $3,801.89 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,884.03 / $4,466.84
| Facility | | $1,905.46 | $2,884.03 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,388.44 / $15,135.61
| Professional | | $1,905.46 | $3,388.44 | $15,135.61 |
- 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
- $1,905.46 / $2,884.03 / $4,466.84
| Professional | | $1,905.46 | $2,884.03 | $4,466.84 |