- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $3,162.28
| Facility | | $1,513.56 | $2,137.96 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $2,884.03
| Professional | | $1,513.56 | $2,137.96 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $245.47 / $1,148.15
| Facility | | $194.98 | $245.47 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,344.23 / $3,801.89
| Professional | | $1,513.56 | $2,344.23 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $4,570.88 / $18,197.01
| Facility | | $794.33 | $4,570.88 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,168.69 / $5,248.07
| Professional | | $2,818.38 | $4,168.69 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $1,122.02 / $2,290.87
| Facility | | $147.91 | $1,122.02 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $2,691.53
| Professional | | $1,148.15 | $1,659.59 | $2,691.53 |