- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $5,248.07
| Facility | | $1,949.84 | $2,818.38 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $1,698.24
| Professional | | $1,258.93 | $1,513.56 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $5,248.07
| Facility | | $2,137.96 | $3,019.95 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $2,137.96 / $3,090.30
| Professional | | $870.96 | $2,137.96 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,949.84 / $7,079.46
| Facility | | $1,258.93 | $1,949.84 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $4,265.80
| Professional | | $2,630.27 | $3,630.78 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,122.02 / $3,090.30
| Professional | | $870.96 | $1,122.02 | $3,090.30 |