- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,398.83 / $7,762.47
| Facility | | $2,089.30 | $2,398.83 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,819.70 / $4,073.80
| Professional | | $1,479.11 | $1,819.70 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,454.71 / $3,162.28
| Professional | | $1,318.26 | $2,454.71 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $2,398.83
| Professional | | $32.36 | $33.11 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,511.89 / $4,466.84
| Facility | | $1,905.46 | $2,511.89 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,454.71 / $3,162.28
| Professional | | $1,318.26 | $2,454.71 | $3,162.28 |
- 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
- $1,819.70 / $2,454.71 / $3,981.07
| Professional | | $1,819.70 | $2,454.71 | $3,981.07 |