- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $7,244.36 / $13,803.84
| Facility | | $2,041.74 | $7,244.36 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,344.23 / $3,235.94
| Professional | | $2,041.74 | $2,344.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,090.30 / $4,073.80
| Professional | | $2,951.21 | $3,090.30 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $7,244.36 / $16,595.87
| Facility | | $1,905.46 | $7,244.36 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $3,981.07
| Facility | | $1,905.46 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,951.21 / $3,467.37
| Facility | | $2,630.27 | $2,951.21 | $3,467.37 |
- 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 |