- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,977.63 / $1,977.63 / $2,923.46
| Facility | | $1,977.63 | $1,977.63 | $2,923.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.57 / $2,736.41 / $2,959.80
| Professional | | $1,885.57 | $2,736.41 | $2,959.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.86 / $3,597.80 / $3,686.40
| Professional | | $2,230.86 | $3,597.80 | $3,686.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.58 / $602.40 / $3,920.54
| Facility | | $328.58 | $602.40 | $3,920.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.84 / $602.40 / $5,684.78
| Professional | | $346.84 | $602.40 | $5,684.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $4,847.72
| Facility | | $2,446.40 | $2,446.40 | $4,847.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,446.40 / $2,792.28
| Professional | | $286.94 | $2,446.40 | $2,792.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.60 / $257.77 / $2,577.75
| Professional | | $178.60 | $257.77 | $2,577.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.25 / $1,866.10 / $3,198.00
| Professional | | $995.25 | $1,866.10 | $3,198.00 |