- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $7,762.47
| Facility | | $2,089.30 | $2,187.76 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $3,388.44
| Professional | | $1,412.54 | $1,584.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $2,691.53
| Professional | | $1,412.54 | $2,089.30 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $2,041.74
| Professional | | $32.36 | $33.11 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,089.30 / $3,162.28
| Facility | | $1,548.82 | $2,089.30 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $2,691.53
| Professional | | $1,412.54 | $2,089.30 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,128.61 / $19,498.45
| Facility | | $3,090.30 | $5,128.61 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $3,235.94
| Professional | | $1,548.82 | $2,041.74 | $3,235.94 |