- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,062.79 / $2,578.48 / $14,886.50
| Facility | | $2,062.79 | $2,578.48 | $14,886.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.79 / $2,406.59 / $3,094.19
| Professional | | $2,062.79 | $2,406.59 | $3,094.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,696.97 / $2,262.62 / $4,927.49
| Facility | | $1,696.97 | $2,262.62 | $4,927.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,187.37 / $4,187.37 / $5,016.93
| Professional | | $4,187.37 | $4,187.37 | $5,016.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.79 / $2,062.79 / $3,005.07
| Professional | | $2,062.79 | $2,062.79 | $3,005.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,437.98 / $3,437.98 / $5,156.97
| Facility | | $3,437.98 | $3,437.98 | $5,156.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.29 / $1,443.95 / $5,386.83
| Professional | | $1,203.29 | $1,443.95 | $5,386.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.79 / $2,062.79 / $2,062.79
| Professional | | $2,062.79 | $2,062.79 | $2,062.79 |