- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,337.65 / $3,155.83 / $5,610.36
| Facility | | $2,337.65 | $3,155.83 | $5,610.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $1,169.00 / $5,610.36
| Professional | | $6.00 | $1,169.00 | $5,610.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,519.47 / $1,519.47 / $6,245.02
| Facility | | $1,519.47 | $1,519.47 | $6,245.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.44 / $2,847.32 / $3,411.41
| Professional | | $1,041.44 | $2,847.32 | $3,411.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,337.65 / $3,272.71 / $11,103.84
| Facility | | $2,337.65 | $3,272.71 | $11,103.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.81 / $981.81 / $3,506.48
| Professional | | $981.81 | $981.81 | $3,506.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,805.18 / $2,805.18 / $2,805.18
| Facility | | $2,805.18 | $2,805.18 | $2,805.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.81 / $981.81 / $1,496.10
| Professional | | $981.81 | $981.81 | $1,496.10 |