- 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 / $5,532.86 / $11,502.66
| Facility | | $2,453.73 | $5,532.86 | $11,502.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.30 / $2,231.30 / $2,231.30
| Professional | | $2,231.30 | $2,231.30 | $2,231.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,635.72 / $3,288.38 / $4,573.60
| Professional | | $2,635.72 | $3,288.38 | $4,573.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $6,950.00 / $8,702.00
| Facility | | $2,510.21 | $6,950.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $3,346.94
| Professional | | $1,054.29 | $1,506.13 | $3,346.94 |