- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,511.89 / $2,511.89
| Facility | | $1,548.82 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,548.82 / $1,737.80
| Professional | | $870.96 | $1,548.82 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,265.80 / $5,370.32
| Professional | | $2,570.40 | $4,265.80 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,137.96 / $10,471.29
| Facility | | $2,089.30 | $2,137.96 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $2,691.53
| Professional | | $1,122.02 | $1,122.02 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,128.61 / $6,165.95
| Professional | | $3,162.28 | $5,128.61 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,951.21
| Professional | | $933.25 | $1,318.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |