- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $2,951.21 / $3,467.37
| Facility | | $181.97 | $2,951.21 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,311.31
| Professional | | $2,951.21 | $2,951.21 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,548.13 / $9,549.93
| Facility | | $2,951.21 | $3,548.13 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $2,951.21 / $3,981.07
| Professional | | $151.36 | $2,951.21 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,951.21 / $2,951.21
| Facility | | $2,818.38 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $2,951.21 / $2,951.21
| Professional | | $186.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $5,623.41
| Facility | | $2,884.03 | $3,801.89 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $2,630.27 / $2,884.03
| Professional | | $125.89 | $2,630.27 | $2,884.03 |