- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,064.94 / $2,753.25 / $6,607.80
| Facility | | $2,064.94 | $2,753.25 | $6,607.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,037.41 / $2,037.41 / $2,945.98
| Professional | | $2,037.41 | $2,037.41 | $2,945.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,789.61 / $1,789.61 / $7,355.30
| Facility | | $1,789.61 | $1,789.61 | $7,355.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,353.83 / $3,353.83 / $4,018.27
| Professional | | $3,353.83 | $3,353.83 | $4,018.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,037.41 / $2,684.42 / $4,625.46
| Facility | | $2,037.41 | $2,684.42 | $4,625.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.36 / $1,156.36 / $4,129.88
| Professional | | $1,156.36 | $1,156.36 | $4,129.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.36 / $1,156.36 / $2,753.25
| Professional | | $1,156.36 | $1,156.36 | $2,753.25 |