- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,365.16 / $5,623.41
| Facility | | $2,089.30 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,187.76 / $2,511.89
| Professional | | $1,819.70 | $2,187.76 | $2,511.89 |
- 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
- $2,089.30 / $3,311.31 / $16,982.44
| Professional | | $2,089.30 | $3,311.31 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,467.37 / $6,309.57
| Professional | | $2,344.23 | $3,467.37 | $6,309.57 |