- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,126.89 / $2,817.23 / $12,161.90
| Facility | | $1,126.89 | $2,817.23 | $12,161.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.89 / $1,658.44 / $1,807.27
| Professional | | $1,126.89 | $1,658.44 | $1,807.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,078.36 / $3,140.75 / $6,694.67
| Facility | | $2,078.36 | $3,140.75 | $6,694.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,232.51 / $2,785.32 / $3,873.94
| Professional | | $2,232.51 | $2,785.32 | $3,873.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.75 / $291.75 / $8,702.00
| Facility | | $291.75 | $291.75 | $8,702.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $999.31 / $2,126.19 / $4,364.17
| Facility | | $999.31 | $2,126.19 | $4,364.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.00 / $1,275.72 / $2,168.71
| Professional | | $893.00 | $1,275.72 | $2,168.71 |