- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $7,762.47 / $7,762.47
| Facility | | $2,089.30 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,905.46 / $2,951.21
| Professional | | $1,047.13 | $1,905.46 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,818.38
| Professional | | $2,344.23 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $60.26 / $1,513.56
| Professional | | $50.12 | $60.26 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,454.71 / $3,090.30
| Facility | | $1,047.13 | $2,454.71 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,715.35
| Professional | | $3,235.94 | $3,235.94 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $9,120.11 / $31,622.78
| Facility | | $794.33 | $9,120.11 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $912.01 / $2,570.40
| Professional | | $602.56 | $912.01 | $2,570.40 |