- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $7,585.78
| Facility | | $2,398.83 | $2,691.53 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $3,981.07
| Professional | | $1,621.81 | $1,949.84 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,344.23 / $4,897.79
| Facility | | $1,258.93 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,691.53 / $4,168.69
| Professional | | $1,949.84 | $2,691.53 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $3,715.35
| Professional | | $1,698.24 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $19,054.61 / $19,054.61
| Facility | | $5,011.87 | $19,054.61 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,182.57 / $16,982.44 / $16,982.44
| Professional | | $13,182.57 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,630.27 / $4,786.30
| Facility | | $1,258.93 | $2,630.27 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $3,548.13
| Professional | | $1,548.82 | $2,137.96 | $3,548.13 |