- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,330.41 / $3,326.03 / $14,358.40
| Facility | | $1,330.41 | $3,326.03 | $14,358.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.41 / $1,957.96 / $2,133.67
| Professional | | $1,330.41 | $1,957.96 | $2,133.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,453.73 / $3,708.15 / $7,904.71
| Facility | | $2,453.73 | $3,708.15 | $7,904.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.15 / $3,288.38 / $4,573.60
| Professional | | $1,757.15 | $3,288.38 | $4,573.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.00 / $2,711.10 / $12,381.00
| Facility | | $1,165.00 | $2,711.10 | $12,381.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $2,711.03
| Professional | | $1,054.29 | $1,506.13 | $2,711.03 |