- 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
- $1,479.11 / $1,905.46 / $4,168.69
| Professional | | $1,479.11 | $1,905.46 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,041.74 / $3,311.31
| Professional | | $977.24 | $2,041.74 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $2,511.89
| Professional | | $32.36 | $33.11 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,187.76 / $3,388.44
| Facility | | $1,513.56 | $2,187.76 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,949.84 / $3,311.31
| Professional | | $977.24 | $1,949.84 | $3,311.31 |
- 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
- $1,659.59 / $1,995.26 / $3,388.44
| Professional | | $1,659.59 | $1,995.26 | $3,388.44 |