- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,995.26 / $8,511.38
| Facility | | $1,905.46 | $1,995.26 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,995.26 / $2,884.03
| Professional | | $1,778.28 | $1,995.26 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,570.88 / $5,495.41
| Professional | | $3,715.35 | $4,570.88 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,715.35 / $6,456.54
| Professional | | $2,691.53 | $3,715.35 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,951.21 / $5,888.44
| Facility | | $1,995.26 | $2,951.21 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,630.78 / $4,265.80
| Professional | | $1,862.09 | $3,630.78 | $4,265.80 |
- 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
- $1,862.09 / $3,630.78 / $4,786.30
| Professional | | $1,862.09 | $3,630.78 | $4,786.30 |