- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,547.39 / $3,868.48 / $16,700.09
| Facility | | $1,547.39 | $3,868.48 | $16,700.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.39 / $2,277.29 / $2,481.66
| Professional | | $1,547.39 | $2,277.29 | $2,481.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.91 / $4,312.79 / $9,193.70
| Facility | | $2,853.91 | $4,312.79 | $9,193.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,065.58 / $3,824.68 / $5,319.51
| Professional | | $3,065.58 | $3,824.68 | $5,319.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $8,702.00
| Facility | | $2,919.60 | $2,919.60 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.38 / $1,751.76 / $2,977.99
| Professional | | $1,130.38 | $1,751.76 | $2,977.99 |