- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,691.53 / $8,128.31
| Facility | | $2,041.74 | $2,691.53 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,041.74 / $2,691.53
| Professional | | $1,905.46 | $2,041.74 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $7,244.36
| Facility | | $1,778.28 | $1,778.28 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,981.07
| Professional | | $3,311.31 | $3,311.31 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $4,677.35
| Facility | | $1,995.26 | $2,691.53 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $10,232.93
| Professional | | $1,148.15 | $1,148.15 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,691.53 / $3,235.94
| Facility | | $1,148.15 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,778.28
| Professional | | $1,148.15 | $1,148.15 | $1,778.28 |