- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,041.74 / $2,691.53
| Facility | | $1,737.80 | $2,041.74 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,041.74 / $2,754.23
| Professional | | $1,479.11 | $2,041.74 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $6,025.60
| Facility | | $190.55 | $190.55 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,905.46 / $3,311.31
| Professional | | $1,258.93 | $1,905.46 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,398.83 / $2,398.83
| Facility | | $2,344.23 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $2,398.83 / $5,011.87
| Professional | | $281.84 | $2,398.83 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $354.81 / $1,949.84
| Facility | | $138.04 | $354.81 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $2,344.23
| Professional | | $891.25 | $1,318.26 | $2,344.23 |