- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,517.44 / $3,679.35 / $16,770.09
| Facility | | $2,517.44 | $3,679.35 | $16,770.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.80 / $2,633.64 / $3,485.70
| Professional | | $2,323.80 | $2,633.64 | $3,485.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,125.31 / $2,975.42 / $14,562.40
| Facility | | $2,125.31 | $2,975.42 | $14,562.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,265.71 / $4,717.52 / $5,652.12
| Professional | | $2,265.71 | $4,717.52 | $5,652.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.80 / $2,323.80 / $3,292.05
| Professional | | $2,323.80 | $2,323.80 | $3,292.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.55 / $1,626.66 / $6,068.45
| Professional | | $1,355.55 | $1,626.66 | $6,068.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.80 / $2,323.80 / $2,323.80
| Professional | | $2,323.80 | $2,323.80 | $2,323.80 |