- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,674.49 / $4,186.22 / $18,071.90
| Facility | | $1,674.49 | $4,186.22 | $18,071.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.49 / $2,464.35 / $2,685.51
| Professional | | $1,674.49 | $2,464.35 | $2,685.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,088.33 / $4,667.35 / $9,948.11
| Facility | | $3,088.33 | $4,667.35 | $9,948.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,317.39 / $4,138.84 / $5,756.46
| Professional | | $3,317.39 | $4,138.84 | $5,756.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,211.59 / $2,211.59 / $8,702.00
| Facility | | $2,211.59 | $2,211.59 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,211.59 / $2,211.59 / $2,211.59
| Professional | | $2,211.59 | $2,211.59 | $2,211.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,484.93 / $3,159.42 / $6,484.92
| Facility | | $1,484.93 | $3,159.42 | $6,484.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.13 / $1,895.65 / $3,222.61
| Professional | | $1,311.13 | $1,895.65 | $3,222.61 |