- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,548.13 / $7,762.47
| Facility | | $2,089.30 | $3,548.13 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $5,495.41
| Professional | | $1,905.46 | $2,454.71 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,235.94 / $4,265.80
| Professional | | $1,737.80 | $3,235.94 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $3,235.94
| Professional | | $32.36 | $33.11 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,162.28 / $5,248.07
| Facility | | $2,238.72 | $3,162.28 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,162.28 / $4,265.80
| Professional | | $1,737.80 | $3,162.28 | $4,265.80 |
- 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
- $2,398.83 / $3,162.28 / $5,128.61
| Professional | | $2,398.83 | $3,162.28 | $5,128.61 |