- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $8,709.64
| Facility | | $2,187.76 | $2,951.21 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $3,388.44
| Professional | | $1,949.84 | $2,290.87 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $7,762.47
| Facility | | $1,905.46 | $1,905.46 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $4,265.80
| Professional | | $3,548.13 | $3,548.13 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,951.21 / $5,128.61
| Facility | | $2,137.96 | $2,951.21 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $10,964.78
| Professional | | $1,230.27 | $1,230.27 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $3,467.37
| Facility | | $1,230.27 | $2,951.21 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,905.46
| Professional | | $1,230.27 | $1,230.27 | $1,905.46 |