- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,570.40 / $5,248.07
| Facility | | $1,995.26 | $2,570.40 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $4,570.88
| Professional | | $1,995.26 | $2,691.53 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,818.38 / $11,220.18
| Facility | | $2,089.30 | $2,818.38 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,818.38 / $6,025.60
| Professional | | $2,754.23 | $2,818.38 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $20,417.38
| Facility | | $3,548.13 | $3,548.13 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $7,943.28
| Professional | | $2,570.40 | $2,570.40 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,548.13 / $6,165.95
| Facility | | $3,019.95 | $3,548.13 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $3,801.89
| Professional | | $1,819.70 | $2,454.71 | $3,801.89 |