- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,754.23 / $3,311.31
| Facility | | $2,187.76 | $2,754.23 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,754.23 / $3,548.13
| Professional | | $1,905.46 | $2,754.23 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $6,606.93
| Facility | | $199.53 | $199.53 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $3,981.07
| Professional | | $1,479.11 | $2,238.72 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,235.94
| Facility | | $2,454.71 | $2,454.71 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,454.71 / $5,495.41
| Professional | | $2,089.30 | $2,454.71 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $457.09 / $2,511.89
| Facility | | $208.93 | $457.09 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,862.09 / $3,235.94
| Professional | | $1,202.26 | $1,862.09 | $3,235.94 |