- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,019.95 / $3,467.37
| Facility | | $1,380.38 | $3,019.95 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,019.95 / $3,467.37
| Professional | | $1,513.56 | $3,019.95 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $251.19 / $5,888.44
| Facility | | $186.21 | $251.19 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,187.76 / $5,495.41
| Professional | | $1,148.15 | $2,187.76 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $5,011.87 / $18,197.01
| Facility | | $870.96 | $5,011.87 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $4,265.80 / $5,370.32
| Professional | | $1,288.25 | $4,265.80 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,380.38 / $3,715.35
| Facility | | $295.12 | $1,380.38 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,019.95 / $5,370.32
| Professional | | $1,445.44 | $3,019.95 | $5,370.32 |