- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $8,511.38 / $8,511.38
| Facility | | $3,801.89 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $3,090.30
| Professional | | $1,621.81 | $1,995.26 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $13,489.63 / $21,877.62
| Facility | | $5,248.07 | $13,489.63 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $5,248.07
| Professional | | $3,801.89 | $3,801.89 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,951.21 / $4,677.35
| Facility | | $1,621.81 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,691.53 / $2,691.53
| Professional | | $2,570.40 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,479.11
| Professional | | $1,023.29 | $1,023.29 | $1,479.11 |