- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $4,786.30
| Facility | | $2,290.87 | $3,162.28 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,019.95 / $4,073.80
| Professional | | $2,187.76 | $3,019.95 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $9,772.37
| Facility | | $295.12 | $295.12 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,890.45 / $5,370.32
| Professional | | $2,754.23 | $3,890.45 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $5,248.07
| Facility | | $3,235.94 | $3,235.94 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,235.94 / $7,585.78
| Professional | | $2,238.72 | $3,235.94 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $1,949.84 / $3,801.89
| Facility | | $234.42 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $4,365.16
| Professional | | $1,819.70 | $2,630.27 | $4,365.16 |