- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,032.46 / $3,008.04 / $6,503.88
| Facility | | $2,032.46 | $3,008.04 | $6,503.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.36 / $2,005.36 / $2,032.46
| Professional | | $2,005.36 | $2,005.36 | $2,032.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,761.47 / $1,761.47 / $7,239.64
| Facility | | $1,761.47 | $1,761.47 | $7,239.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,300.86 / $3,300.86 / $3,954.81
| Professional | | $3,300.86 | $3,300.86 | $3,954.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,005.36 / $2,709.95 / $4,552.72
| Facility | | $2,005.36 | $2,709.95 | $4,552.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.18 / $1,138.18 / $10,176.49
| Professional | | $1,138.18 | $1,138.18 | $10,176.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.18 / $1,138.18 / $2,709.95
| Professional | | $1,138.18 | $1,138.18 | $2,709.95 |