- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $2,884.03
| Facility | | $1,380.38 | $1,862.09 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $2,454.71
| Professional | | $1,288.25 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $5,888.44
| Facility | | $173.78 | $173.78 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,290.87 / $3,388.44
| Professional | | $1,659.59 | $2,290.87 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $3,162.28
| Facility | | $1,862.09 | $1,862.09 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,862.09 / $4,570.88
| Professional | | $1,584.89 | $1,862.09 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $1,412.54 / $2,630.27
| Facility | | $177.83 | $1,412.54 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,905.46 / $3,090.30
| Professional | | $1,288.25 | $1,905.46 | $3,090.30 |