- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,570.88 / $10,715.19
| Facility | | $3,388.44 | $4,570.88 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $2,818.38
| Professional | | $1,905.46 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $8,709.64
| Facility | | $2,951.21 | $2,951.21 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $2,454.71
| Professional | | $1,174.90 | $1,174.90 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $63,095.73
| Facility | | $2,570.40 | $4,570.88 | $63,095.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $11,481.54
| Facility | | $1,905.46 | $1,905.46 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,548.13 / $8,709.64
| Professional | | $1,548.82 | $3,548.13 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,951.21
| Professional | | $1,230.27 | $1,737.80 | $2,951.21 |