- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,159.42 / $3,633.33 / $6,318.84
| Facility | | $3,159.42 | $3,633.33 | $6,318.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.00 / $3,064.64 / $3,633.33
| Professional | | $477.00 | $3,064.64 | $3,633.33 |
- 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
- $1,741.97 / $2,009.97 / $2,371.76
| Professional | | $1,741.97 | $2,009.97 | $2,371.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,012.55 / $2,567.03 / $6,838.55
| Facility | | $2,012.55 | $2,567.03 | $6,838.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,326.96 / $3,159.42
| Professional | | $1,326.96 | $1,326.96 | $3,159.42 |