- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,029.90 / $2,390.15 / $11,115.20
| Facility | | $1,029.90 | $2,390.15 | $11,115.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.90 / $1,457.41 / $1,651.73
| Professional | | $1,029.90 | $1,457.41 | $1,651.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,899.49 / $2,870.84 / $6,118.47
| Facility | | $1,899.49 | $2,870.84 | $6,118.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,040.37 / $2,545.61 / $3,540.53
| Professional | | $2,040.37 | $2,545.61 | $3,540.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $619.09 / $619.09 / $8,702.00
| Facility | | $619.09 | $619.09 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.28 / $1,165.93 / $1,943.21
| Professional | | $777.28 | $1,165.93 | $1,943.21 |