- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,139.23 / $2,161.94 / $2,403.66
| Facility | | $2,139.23 | $2,161.94 | $2,403.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.96 / $2,161.94 / $2,719.76
| Professional | | $1,743.96 | $2,161.94 | $2,719.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,339.10 / $2,339.10 / $4,514.46
| Facility | | $2,339.10 | $2,339.10 | $4,514.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.05 / $2,339.10 / $2,972.28
| Professional | | $2,255.05 | $2,339.10 | $2,972.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,360.50 / $3,367.85 / $3,367.85
| Facility | | $3,360.50 | $3,367.85 | $3,367.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.14 / $2,837.98 / $5,170.31
| Professional | | $302.14 | $2,837.98 | $5,170.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.58 / $1,713.46 / $2,399.38
| Professional | | $1,196.58 | $1,713.46 | $2,399.38 |