- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,055.86 / $2,055.86 / $2,055.86
| Facility | | $2,055.86 | $2,055.86 | $2,055.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.33 / $1,431.30 / $2,290.08
| Professional | | $734.33 | $1,431.30 | $2,290.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,103.51 / $2,295.03 / $2,434.32
| Facility | | $2,103.51 | $2,295.03 | $2,434.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,278.00 / $2,278.00 / $2,278.00
| Professional | | $2,278.00 | $2,278.00 | $2,278.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,424.68 / $1,424.68 / $1,424.68
| Facility | | $1,424.68 | $1,424.68 | $1,424.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.02 / $1,040.02 / $4,348.59
| Professional | | $1,040.02 | $1,040.02 | $4,348.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $734.33 / $2,203.46 / $12,107.67
| Facility | | $734.33 | $2,203.46 | $12,107.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.31 / $1,523.44 / $3,492.97
| Professional | | $758.31 | $1,523.44 | $3,492.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.34 / $1,364.02 / $1,804.01
| Professional | | $909.34 | $1,364.02 | $1,804.01 |