- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,290.87 / $8,912.51
| Facility | | $2,187.76 | $2,290.87 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $3,981.07
| Professional | | $1,479.11 | $1,737.80 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,290.87 / $2,951.21
| Professional | | $1,230.27 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $2,238.72
| Professional | | $32.36 | $33.11 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,290.87 / $3,715.35
| Facility | | $1,445.44 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,290.87 / $2,951.21
| Professional | | $1,230.27 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $11,220.18 / $25,703.96
| Facility | | $891.25 | $11,220.18 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,290.87 / $3,630.78
| Professional | | $1,737.80 | $2,290.87 | $3,630.78 |