- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.58 / $2,284.46 / $2,459.51
| Professional | | $1,753.58 | $2,284.46 | $2,459.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $4,590.37 / $4,590.37
| Professional | | $0.02 | $4,590.37 | $4,590.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,259.94 / $2,722.57 / $4,939.95
| Professional | | $2,259.94 | $2,722.57 | $4,939.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,890.14 / $3,147.80 / $4,572.37
| Professional | | $1,890.14 | $3,147.80 | $4,572.37 |