- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $3,235.94
| Facility | | $2,187.76 | $2,570.40 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,570.40 / $3,388.44
| Professional | | $1,819.70 | $2,570.40 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $229.09 / $6,606.93
| Facility | | $229.09 | $229.09 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,884.03 / $3,801.89
| Professional | | $1,737.80 | $2,884.03 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $2,691.53 / $5,623.41
| Professional | | $316.23 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $407.38 / $2,344.23
| Facility | | $186.21 | $407.38 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,659.59 / $2,951.21
| Professional | | $1,122.02 | $1,659.59 | $2,951.21 |