- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,137.96 / $7,585.78
| Facility | | $1,995.26 | $2,137.96 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,089.30 / $2,511.89
| Professional | | $2,041.74 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,511.89 / $4,897.79
| Facility | | $1,288.25 | $2,511.89 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,089.30 / $2,511.89
| Professional | | $977.24 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $2,137.96
| Facility | | $1,584.89 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $3,235.94
| Professional | | $2,137.96 | $2,137.96 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $831.76 / $1,513.56
| Facility | | $776.25 | $831.76 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,511.89
| Professional | | $2,089.30 | $2,089.30 | $2,511.89 |