- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,556.85 / $2,880.17 / $5,833.00
| Facility | | $1,556.85 | $2,880.17 | $5,833.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.85 / $1,639.88 / $1,764.43
| Professional | | $1,556.85 | $1,639.88 | $1,764.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.42 / $1,349.27 / $3,321.28
| Professional | | $1,079.42 | $1,349.27 | $3,321.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,369.51 / $4,272.85 / $9,226.35
| Facility | | $1,369.51 | $4,272.85 | $9,226.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.73 / $2,385.08 / $2,981.34
| Professional | | $2,075.73 | $2,385.08 | $2,981.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,611.89 / $9,860.04 / $9,860.04
| Facility | | $3,611.89 | $9,860.04 | $9,860.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $1,245.48 / $2,075.80
| Professional | | $871.84 | $1,245.48 | $2,075.80 |