- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,651.73 / $2,612.30 / $4,508.25
| Facility | | $1,651.73 | $2,612.30 | $4,508.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.73 / $1,690.59 / $1,884.91
| Professional | | $1,651.73 | $1,690.59 | $1,884.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.14 / $1,734.31 / $3,441.72
| Professional | | $1,090.14 | $1,734.31 | $3,441.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,676.49 / $3,752.64 / $4,631.75
| Facility | | $2,676.49 | $3,752.64 | $4,631.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.00 / $2,255.00 / $2,255.00
| Professional | | $2,255.00 | $2,255.00 | $2,255.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,651.73 / $2,331.85 / $9,230.25
| Facility | | $1,651.73 | $2,331.85 | $9,230.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $1,165.93 / $9,677.19
| Professional | | $816.15 | $1,165.93 | $9,677.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $1,165.93 / $2,197.77
| Professional | | $816.15 | $1,165.93 | $2,197.77 |