- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,754.23 / $4,265.80
| Facility | | $2,137.96 | $2,754.23 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,691.53 / $3,630.78
| Professional | | $1,862.09 | $2,691.53 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $8,511.38
| Facility | | $269.15 | $269.15 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,630.78 / $4,677.35
| Professional | | $2,570.40 | $3,630.78 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $4,570.88
| Facility | | $2,187.76 | $2,187.76 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $6,606.93
| Professional | | $1,862.09 | $2,187.76 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $1,778.28 / $3,467.37
| Facility | | $208.93 | $1,778.28 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,398.83 / $3,981.07
| Professional | | $1,659.59 | $2,398.83 | $3,981.07 |