- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,089.30 / $3,090.30
| Facility | | $1,348.96 | $2,089.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,238.72 / $3,235.94
| Professional | | $1,318.26 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $446.68 / $2,041.74
| Facility | | $346.74 | $446.68 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,995.26 / $4,786.30
| Professional | | $1,479.11 | $1,995.26 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,715.35 / $8,912.51
| Facility | | $1,230.27 | $3,715.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,235.94 / $3,715.35
| Professional | | $2,884.03 | $3,235.94 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $354.81 / $2,884.03
| Facility | | $138.04 | $354.81 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $467.74 / $3,090.30
| Professional | | $154.88 | $467.74 | $3,090.30 |