- 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
- $3,057.46 / $3,057.46 / $3,663.18
| Professional | | $3,057.46 | $3,057.46 | $3,663.18 |
- 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 / $1,171.43 / $3,765.32
| Professional | | $1,054.29 | $1,171.43 | $3,765.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,171.43 / $1,673.47
| Professional | | $1,054.29 | $1,171.43 | $1,673.47 |