- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,981.07 / $7,762.47
| Facility | | $2,137.96 | $3,981.07 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $3,981.07
| Professional | | $2,089.30 | $2,511.89 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,025.60 / $7,762.47
| Facility | | $3,715.35 | $6,025.60 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $4,897.79
| Professional | | $2,089.30 | $2,754.23 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $4,365.16
| Professional | | $2,041.74 | $2,754.23 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $14.13 / $16.22
| Professional | | $14.13 | $14.13 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.30 / $12.30 / $12.30
| Professional | | $12.30 | $12.30 | $12.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,090.30 / $9,120.11
| Facility | | $1,659.59 | $3,090.30 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,754.23 / $4,786.30
| Professional | | $2,187.76 | $2,754.23 | $4,786.30 |