- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,411.37 / $2,411.37 / $3,473.83
| Facility | | $2,411.37 | $2,411.37 | $3,473.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.26 / $2,605.38 / $2,605.38
| Professional | | $935.26 | $2,605.38 | $2,605.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.15 / $2,779.07 / $5,210.76
| Facility | | $1,042.15 | $2,779.07 | $5,210.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,607.58 / $2,605.38 / $2,865.92
| Facility | | $1,607.58 | $2,605.38 | $2,865.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,336.09 / $1,603.31
| Professional | | $1,336.09 | $1,336.09 | $1,603.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $78.00 / $2,605.38
| Professional | | $30.00 | $78.00 | $2,605.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,004.14 / $2,672.18 / $4,809.92
| Facility | | $2,004.14 | $2,672.18 | $4,809.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.97 / $1,996.97 / $2,063.77
| Professional | | $1,996.97 | $1,996.97 | $2,063.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $561.16 / $1,536.50
| Professional | | $561.16 | $561.16 | $1,536.50 |