- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,863.22 / $2,142.69 / $3,726.44
| Facility | | $1,863.22 | $2,142.69 | $3,726.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.31 / $2,142.69 / $2,142.69
| Professional | | $1,453.31 | $2,142.69 | $2,142.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.67 / $69.98 / $94.15
| Facility | | $57.67 | $69.98 | $94.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.30 / $870.00 / $1,208.95
| Professional | | $716.30 | $870.00 | $1,208.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,465.42 / $1,574.42 / $5,843.08
| Facility | | $1,465.42 | $1,574.42 | $5,843.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $782.55 / $1,117.93
| Professional | | $782.55 | $782.55 | $1,117.93 |