- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,818.38 / $7,762.47
| Facility | | $2,089.30 | $2,818.38 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,949.84 / $4,168.69
| Professional | | $1,513.56 | $1,949.84 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,454.71 / $3,388.44
| Professional | | $1,318.26 | $2,454.71 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $2,570.40
| Professional | | $32.36 | $33.11 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,290.87 / $3,801.89
| Facility | | $1,778.28 | $2,290.87 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,398.83 / $3,388.44
| Professional | | $1,318.26 | $2,398.83 | $3,388.44 |
- 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
- $1,778.28 / $2,398.83 / $3,981.07
| Professional | | $1,778.28 | $2,398.83 | $3,981.07 |