- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $4,897.79
| Facility | | $1,380.38 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,344.23 / $3,019.95
| Professional | | $1,096.48 | $2,344.23 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $25,703.96 / $35,481.34
| Facility | | $10,232.93 | $25,703.96 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,981.07 / $6,165.95
| Professional | | $3,019.95 | $3,981.07 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,089.30 / $2,290.87
| Facility | | $1,949.84 | $2,089.30 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $14,454.40
| Professional | | $1,949.84 | $2,884.03 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $3,981.07
| Professional | | $1,479.11 | $2,187.76 | $3,981.07 |