- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,905.46 / $8,511.38
| Facility | | $1,778.28 | $1,905.46 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,949.84 / $2,754.23
| Professional | | $1,778.28 | $1,949.84 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,073.80 / $4,786.30
| Professional | | $3,311.31 | $4,073.80 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,548.13 / $5,754.40
| Professional | | $2,398.83 | $3,548.13 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,818.38 / $5,754.40
| Facility | | $1,905.46 | $2,818.38 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,467.37 / $4,073.80
| Professional | | $1,905.46 | $3,467.37 | $4,073.80 |
- 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
- $1,905.46 / $3,467.37 / $4,786.30
| Professional | | $1,905.46 | $3,467.37 | $4,786.30 |