- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,548.13 / $4,365.16
| Facility | | $2,238.72 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,238.72 / $5,011.87
| Professional | | $1,380.38 | $2,238.72 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,511.89 / $3,019.95
| Professional | | $1,995.26 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $6,606.93 / $8,128.31
| Facility | | $1,698.24 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,570.40 / $27,542.29
| Professional | | $1,202.26 | $2,570.40 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $3,019.95
| Professional | | $2,511.89 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,548.13 / $7,762.47
| Professional | | $1,202.26 | $3,548.13 | $7,762.47 |