- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,511.89 / $3,019.95
| Facility | | $1,737.80 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,162.28
| Professional | | $1,778.28 | $2,398.83 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $7,762.47
| Facility | | $275.42 | $275.42 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,754.23 / $4,265.80
| Professional | | $1,698.24 | $2,754.23 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $2,570.40 / $6,025.60
| Professional | | $309.03 | $2,570.40 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $269.15 / $2,754.23
| Facility | | $138.04 | $269.15 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $199.53 / $2,089.30
| Professional | | $123.03 | $199.53 | $2,089.30 |