- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $13,182.57 / $16,982.44
| Facility | | $2,454.71 | $13,182.57 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,454.71 / $3,388.44
| Professional | | $1,479.11 | $2,454.71 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,398.83 / $7,413.10
| Facility | | $2,290.87 | $2,398.83 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Professional | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $12,589.25
| Facility | | $2,290.87 | $2,691.53 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,691.53
| Professional | | $2,290.87 | $2,290.87 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $7,762.47
| Professional | | $1,905.46 | $1,905.46 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $4,073.80
| Professional | | $2,137.96 | $2,398.83 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,621.81
| Professional | | $1,148.15 | $1,148.15 | $1,621.81 |