- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,394.07 / $3,649.50 / $7,944.75
| Facility | | $2,394.07 | $3,649.50 | $7,944.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.53 / $2,394.07 / $2,919.60
| Professional | | $1,941.53 | $2,394.07 | $2,919.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,825.30 / $3,226.16 / $10,093.06
| Facility | | $2,825.30 | $3,226.16 | $10,093.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.83 / $1,284.61 / $2,919.60
| Professional | | $1,167.83 | $1,284.61 | $2,919.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,918.93 / $3,925.74 / $7,896.77
| Facility | | $1,918.93 | $3,925.74 | $7,896.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.97 / $3,354.80 / $4,960.85
| Professional | | $1,707.97 | $3,354.80 | $4,960.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $2,919.60
| Facility | | $2,919.60 | $2,919.60 | $2,919.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $3,503.52
| Professional | | $1,226.23 | $1,751.76 | $3,503.52 |