- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,422.75 / $2,105.67 / $4,552.80
| Facility | | $1,422.75 | $2,105.67 | $4,552.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.78 / $1,403.78 / $1,422.75
| Professional | | $1,403.78 | $1,403.78 | $1,422.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.05 / $1,233.05 / $5,067.84
| Facility | | $1,233.05 | $1,233.05 | $5,067.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,311.04 / $2,311.04 / $2,768.89
| Professional | | $2,311.04 | $2,311.04 | $2,768.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,403.78 / $1,897.00 / $3,186.96
| Facility | | $1,403.78 | $1,897.00 | $3,186.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $796.74 / $2,845.50
| Professional | | $796.74 | $796.74 | $2,845.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $796.74 / $1,897.00
| Professional | | $796.74 | $796.74 | $1,897.00 |