- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,166.85 / $2,917.15 / $12,593.30
| Facility | | $1,166.85 | $2,917.15 | $12,593.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.85 / $1,444.93 / $1,871.38
| Professional | | $1,166.85 | $1,444.93 | $1,871.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,152.08 / $2,785.05 / $7,426.52
| Facility | | $2,152.08 | $2,785.05 | $7,426.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.85 / $2,529.63 / $3,162.03
| Professional | | $1,166.85 | $2,529.63 | $3,162.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.65 / $1,100.81 / $1,320.97
| Professional | | $880.65 | $1,100.81 | $1,320.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,541.13 / $1,541.13 / $8,702.00
| Facility | | $1,541.13 | $1,541.13 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.13 / $1,541.13 / $1,541.13
| Professional | | $1,541.13 | $1,541.13 | $1,541.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.65 / $1,320.97 / $2,256.66
| Professional | | $880.65 | $1,320.97 | $2,256.66 |