- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.48 / $3,765.31 / $14,358.40
| Facility | | $1,642.48 | $3,765.31 | $14,358.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.48 / $2,058.37 / $2,634.17
| Professional | | $1,642.48 | $2,058.37 | $2,634.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,453.73 / $5,532.86 / $11,502.66
| Facility | | $2,453.73 | $5,532.86 | $11,502.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,495.37 / $2,603.34 / $5,383.32
| Professional | | $1,495.37 | $2,603.34 | $5,383.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.15 / $2,635.72 / $3,639.80
| Professional | | $1,757.15 | $2,635.72 | $3,639.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $13,785.00 / $13,785.00
| Facility | | $2,510.21 | $13,785.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $3,176.50
| Professional | | $1,054.29 | $1,506.13 | $3,176.50 |