- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,093.78 / $2,617.21 / $15,110.10
| Facility | | $2,093.78 | $2,617.21 | $15,110.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.85 / $2,372.94 / $3,140.67
| Professional | | $1,901.85 | $2,372.94 | $3,140.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,753.16 / $2,454.42 / $13,121.28
| Facility | | $1,753.16 | $2,454.42 | $13,121.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.33 / $3,859.33 / $4,623.91
| Professional | | $3,859.33 | $3,859.33 | $4,623.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.78 / $2,093.78 / $2,966.19
| Professional | | $2,093.78 | $2,093.78 | $2,966.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.36 / $1,465.64 / $5,467.76
| Professional | | $1,221.36 | $1,465.64 | $5,467.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.78 / $2,093.78 / $2,093.78
| Professional | | $2,093.78 | $2,093.78 | $2,093.78 |