- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.00 / $2,181.55 / $3,794.00
| Facility | | $1,897.00 | $2,181.55 | $3,794.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.66 / $1,840.09 / $2,181.55
| Professional | | $1,479.66 | $1,840.09 | $2,181.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.89 / $652.76 / $878.17
| Facility | | $537.89 | $652.76 | $878.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.13 / $137.13 / $1,230.86
| Professional | | $137.13 | $137.13 | $1,230.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.39 / $1,541.31 / $4,106.06
| Facility | | $1,208.39 | $1,541.31 | $4,106.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $796.74 / $1,138.20
| Professional | | $796.74 | $796.74 | $1,138.20 |