- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,406.59 / $2,681.63 / $16,304.30
| Facility | | $2,406.59 | $2,681.63 | $16,304.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,681.63 / $2,681.63 / $2,750.39
| Professional | | $2,681.63 | $2,681.63 | $2,750.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,437.98 / $3,437.98 / $4,701.43
| Professional | | $3,437.98 | $3,437.98 | $4,701.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,248.19 / $8,469.48 / $19,602.70
| Facility | | $6,248.19 | $8,469.48 | $19,602.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,681.63 / $3,437.98 / $3,520.72
| Facility | | $2,681.63 | $3,437.98 | $3,520.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.95 / $1,890.89 / $3,130.66
| Professional | | $1,443.95 | $1,890.89 | $3,130.66 |