- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,310.55 / $3,919.96 / $6,057.12
| Facility | | $2,310.55 | $3,919.96 | $6,057.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.75 / $1,650.39 / $1,897.00
| Professional | | $1,422.75 | $1,650.39 | $1,897.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.25 / $2,371.25 / $2,371.25
| Professional | | $2,371.25 | $2,371.25 | $2,371.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,676.95 / $3,107.29 / $4,301.46
| Facility | | $1,676.95 | $3,107.29 | $4,301.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.60 / $1,897.00 / $2,552.05
| Facility | | $1,517.60 | $1,897.00 | $2,552.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $1,138.20 / $9,447.06
| Professional | | $796.74 | $1,138.20 | $9,447.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $1,138.20 / $2,845.50
| Professional | | $796.74 | $1,138.20 | $2,845.50 |