- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,550.08 / $3,684.53 / $8,851.01
| Facility | | $2,550.08 | $3,684.53 | $8,851.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.58 / $2,550.08 / $2,714.92
| Professional | | $2,055.58 | $2,550.08 | $2,714.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.68 / $5,691.63 / $9,599.16
| Facility | | $258.68 | $5,691.63 | $9,599.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.00 / $4,072.37 / $5,676.01
| Professional | | $1,978.00 | $4,072.37 | $5,676.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,520.98 / $10,754.27 / $22,261.36
| Facility | | $2,520.98 | $10,754.27 | $22,261.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,460.22 / $7,066.54 / $9,579.77
| Professional | | $4,460.22 | $7,066.54 | $9,579.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $2,327.07 / $6,806.29
| Professional | | $1,628.95 | $2,327.07 | $6,806.29 |