- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,868.60 / $2,955.29 / $5,100.17
| Facility | | $1,868.60 | $2,955.29 | $5,100.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.60 / $1,912.56 / $2,132.40
| Professional | | $1,868.60 | $1,912.56 | $2,132.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.79 / $1,962.02 / $3,893.63
| Professional | | $514.79 | $1,962.02 | $3,893.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,027.90 / $4,245.35 / $5,239.89
| Facility | | $3,027.90 | $4,245.35 | $5,239.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,551.17 / $2,551.17 / $2,551.17
| Professional | | $2,551.17 | $2,551.17 | $2,551.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,868.60 / $2,638.02 / $10,442.16
| Facility | | $1,868.60 | $2,638.02 | $10,442.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $1,319.01 / $10,947.78
| Professional | | $923.31 | $1,319.01 | $10,947.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $1,319.01 / $2,486.33
| Professional | | $923.31 | $1,319.01 | $2,486.33 |