- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,364.56 / $3,411.40 / $14,727.00
| Facility | | $1,364.56 | $3,411.40 | $14,727.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.56 / $2,008.23 / $2,188.44
| Professional | | $1,364.56 | $2,008.23 | $2,188.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,516.71 / $3,803.44 / $8,107.45
| Facility | | $2,516.71 | $3,803.44 | $8,107.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.26 / $3,372.79 / $4,691.01
| Professional | | $1,802.26 | $3,372.79 | $4,691.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,760.50 / $8,702.00 / $12,381.00
| Facility | | $1,760.50 | $8,702.00 | $12,381.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,544.79 / $2,626.14
| Professional | | $1,081.34 | $1,544.79 | $2,626.14 |