- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,344.23 / $3,890.45
| Facility | | $2,238.72 | $2,344.23 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $2,951.21
| Professional | | $1,513.56 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,365.16 / $4,466.84
| Professional | | $3,715.35 | $4,365.16 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,162.28 / $3,715.35
| Professional | | $2,884.03 | $3,162.28 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $9,772.37 / $9,772.37
| Facility | | $100.00 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $354.81 / $2,818.38
| Facility | | $114.82 | $354.81 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $346.74 / $3,090.30
| Professional | | $128.82 | $346.74 | $3,090.30 |