- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,764.43 / $2,708.92 / $3,611.90
| Facility | | $1,764.43 | $2,708.92 | $3,611.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.43 / $1,805.95 / $2,013.53
| Professional | | $1,764.43 | $1,805.95 | $2,013.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.34 / $1,428.15 / $3,694.92
| Professional | | $12.34 | $1,428.15 | $3,694.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,930.61 / $4,354.09 / $4,947.77
| Facility | | $2,930.61 | $4,354.09 | $4,947.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $2,408.92 / $2,981.34
| Professional | | $2,385.08 | $2,408.92 | $2,981.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,660.64 / $2,698.54 / $9,860.04
| Facility | | $1,660.64 | $2,698.54 | $9,860.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $1,245.48 / $2,345.65
| Professional | | $871.84 | $1,245.48 | $2,345.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $1,245.48 / $2,490.96
| Professional | | $871.84 | $1,245.48 | $2,490.96 |