- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.23 / $2,996.84 / $7,209.30
| Facility | | $2,113.23 | $2,996.84 | $7,209.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.37 / $2,889.33 / $4,092.01
| Professional | | $1,776.37 | $2,889.33 | $4,092.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,717.91 / $2,739.83 / $5,676.61
| Facility | | $1,717.91 | $2,739.83 | $5,676.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.64 / $2,569.75 / $3,405.47
| Professional | | $1,501.64 | $2,569.75 | $3,405.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.59 / $1,310.04 / $2,133.50
| Facility | | $1,162.59 | $1,310.04 | $2,133.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,110.00 / $4,110.00 / $4,110.00
| Professional | | $4,110.00 | $4,110.00 | $4,110.00 |