- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,089.30 / $8,511.38
| Facility | | $1,995.26 | $2,089.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,089.30 / $5,128.61
| Professional | | $1,905.46 | $2,089.30 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,677.35 / $5,495.41
| Professional | | $3,801.89 | $4,677.35 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,715.35 / $6,165.95
| Professional | | $2,137.96 | $3,715.35 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $3,715.35
| Facility | | $2,089.30 | $2,630.27 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,630.78 / $15,488.17
| Professional | | $1,905.46 | $3,630.78 | $15,488.17 |
- 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 / $3,715.35 / $5,011.87
| Professional | | $1,905.46 | $3,715.35 | $5,011.87 |