- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,570.40 / $5,495.41
| Facility | | $1,995.26 | $2,570.40 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,570.40 / $4,365.16
| Professional | | $2,041.74 | $2,570.40 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,754.23 / $9,772.37
| Facility | | $1,995.26 | $2,754.23 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,884.03 / $5,754.40
| Professional | | $2,570.40 | $2,884.03 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $20,417.38
| Facility | | $2,754.23 | $2,754.23 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $7,079.46
| Professional | | $1,995.26 | $1,995.26 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,818.38 / $6,025.60
| Facility | | $1,659.59 | $2,818.38 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $3,801.89
| Professional | | $1,698.24 | $2,398.83 | $3,801.89 |