- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,836.42 / $2,076.38 / $6,684.57
| Facility | | $1,836.42 | $2,076.38 | $6,684.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.42 / $1,909.88 / $2,326.13
| Professional | | $1,836.42 | $1,909.88 | $2,326.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.25 / $3,232.10 / $4,823.66
| Professional | | $1,273.25 | $3,232.10 | $4,823.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.66 / $5,275.80 / $8,743.00
| Facility | | $1,639.66 | $5,275.80 | $8,743.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.56 / $2,448.56 / $11,802.06
| Professional | | $2,448.56 | $2,448.56 | $11,802.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,260.49 / $11,630.66 / $11,630.66
| Facility | | $4,260.49 | $11,630.66 | $11,630.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,193.83 / $12,193.83 / $18,364.20
| Professional | | $12,193.83 | $12,193.83 | $18,364.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,469.14 / $2,448.56
| Professional | | $1,028.40 | $1,469.14 | $2,448.56 |