- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,290.55 / $3,226.38 / $13,928.20
| Facility | | $1,290.55 | $3,226.38 | $13,928.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.55 / $1,899.30 / $2,069.75
| Professional | | $1,290.55 | $1,899.30 | $2,069.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,380.21 / $3,080.28 / $8,212.91
| Facility | | $2,380.21 | $3,080.28 | $8,212.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.50 / $3,189.85 / $4,436.57
| Professional | | $1,704.50 | $3,189.85 | $4,436.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,704.50 / $1,704.50 / $8,702.00
| Facility | | $1,704.50 | $1,704.50 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.50 / $1,704.50 / $1,704.50
| Professional | | $1,704.50 | $1,704.50 | $1,704.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.70 / $1,461.00 / $2,483.69
| Professional | | $1,022.70 | $1,461.00 | $2,483.69 |