- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,041.74 / $8,511.38
| Facility | | $1,949.84 | $2,041.74 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $3,019.95
| Professional | | $1,819.70 | $2,041.74 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,786.30 / $5,623.41
| Professional | | $3,801.89 | $4,786.30 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $6,606.93
| Professional | | $2,754.23 | $3,715.35 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,019.95 / $6,025.60
| Facility | | $2,041.74 | $3,019.95 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,715.35 / $4,365.16
| Professional | | $1,995.26 | $3,715.35 | $4,365.16 |
- 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
- $1,995.26 / $3,715.35 / $4,897.79
| Professional | | $1,995.26 | $3,715.35 | $4,897.79 |