- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,011.87 / $5,623.41
| Facility | | $2,754.23 | $5,011.87 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,187.76 / $5,011.87
| Professional | | $1,819.70 | $2,187.76 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Professional | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,862.09
| Facility | | $1,778.28 | $1,778.28 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $21.38 / $50.12
| Professional | | $16.98 | $21.38 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,311.31
| Facility | | $2,454.71 | $2,454.71 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $6,165.95
| Professional | | $1,148.15 | $1,659.59 | $6,165.95 |