- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $3,801.89
| Facility | | $1,819.70 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $3,235.94
| Professional | | $1,698.24 | $2,398.83 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $229.09 / $7,585.78
| Facility | | $229.09 | $229.09 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,019.95 / $4,168.69
| Professional | | $2,187.76 | $3,019.95 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $4,073.80
| Facility | | $2,398.83 | $2,398.83 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $6,025.60
| Professional | | $2,041.74 | $2,398.83 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $1,513.56 / $3,019.95
| Facility | | $181.97 | $1,513.56 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,041.74 / $3,388.44
| Professional | | $1,412.54 | $2,041.74 | $3,388.44 |