- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,388.67 / $2,459.98 / $3,338.81
| Facility | | $2,388.67 | $2,459.98 | $3,338.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.88 / $2,388.67 / $2,459.98
| Professional | | $1,757.88 | $2,388.67 | $2,459.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.25 / $2,495.64 / $2,972.28
| Professional | | $1,949.25 | $2,495.64 | $2,972.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,787.80 / $2,787.80 / $2,787.80
| Facility | | $2,787.80 | $2,787.80 | $2,787.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.76 / $2,837.98 / $5,170.31
| Professional | | $287.76 | $2,837.98 | $5,170.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.16 / $407.16 / $407.16
| Professional | | $407.16 | $407.16 | $407.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.35 / $1,713.46 / $2,286.88
| Professional | | $1,370.35 | $1,713.46 | $2,286.88 |