- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.65 / $2,369.57 / $13,680.30
| Facility | | $1,895.65 | $2,369.57 | $13,680.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.88 / $2,211.59 / $2,843.48
| Professional | | $1,721.88 | $2,211.59 | $2,843.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,586.76 / $2,260.32 / $11,879.00
| Facility | | $1,586.76 | $2,260.32 | $11,879.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,848.09 / $3,848.09 / $4,610.43
| Professional | | $3,848.09 | $3,848.09 | $4,610.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.65 / $1,895.65 / $2,685.51
| Professional | | $1,895.65 | $1,895.65 | $2,685.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.39 / $1,895.65 / $2,843.48
| Facility | | $1,137.39 | $1,895.65 | $2,843.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.80 / $1,326.96 / $4,950.37
| Professional | | $1,105.80 | $1,326.96 | $4,950.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.65 / $1,895.65 / $1,895.65
| Professional | | $1,895.65 | $1,895.65 | $1,895.65 |