- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,882.66 / $2,510.21 / $6,024.50
| Facility | | $1,882.66 | $2,510.21 | $6,024.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.56 / $1,857.56 / $2,685.92
| Professional | | $1,857.56 | $1,857.56 | $2,685.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $1,631.64 / $6,706.04
| Facility | | $1,631.64 | $1,631.64 | $6,706.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,776.14 / $2,776.14 / $3,326.13
| Professional | | $2,776.14 | $2,776.14 | $3,326.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.56 / $2,510.21 / $4,217.14
| Facility | | $1,857.56 | $2,510.21 | $4,217.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,054.29 / $9,426.42
| Professional | | $1,054.29 | $1,054.29 | $9,426.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,054.29 / $1,606.53
| Professional | | $1,054.29 | $1,054.29 | $1,606.53 |