- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,080.19 / $3,357.27
| Facility | | $1,277.00 | $2,080.19 | $3,357.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.78 / $2,080.19 / $2,678.36
| Professional | | $1,730.78 | $2,080.19 | $2,678.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,430.62 / $5,430.62 / $6,516.74
| Facility | | $5,430.62 | $5,430.62 | $6,516.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.85 / $2,503.92 / $2,503.92
| Professional | | $1,891.85 | $2,503.92 | $2,503.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,337.37 / $4,337.37 / $4,337.37
| Facility | | $4,337.37 | $4,337.37 | $4,337.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,724.76 / $2,964.13 / $3,546.92
| Professional | | $1,724.76 | $2,964.13 | $3,546.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,828.00 / $6,992.00
| Facility | | $1,565.00 | $2,828.00 | $6,992.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,760.45 / $2,404.40 / $3,581.53
| Professional | | $1,760.45 | $2,404.40 | $3,581.53 |