- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,089.30 / $2,884.03
| Facility | | $1,862.09 | $2,089.30 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,995.26 / $2,691.53
| Professional | | $1,445.44 | $1,995.26 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $181.97 / $6,025.60
| Facility | | $181.97 | $181.97 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $3,311.31
| Professional | | $1,513.56 | $2,238.72 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,454.71
| Facility | | $2,238.72 | $2,238.72 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $4,677.35
| Professional | | $1,905.46 | $2,238.72 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $331.13 / $1,862.09
| Facility | | $131.83 | $331.13 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $2,238.72
| Professional | | $851.14 | $1,230.27 | $2,238.72 |