- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $7,762.47
| Facility | | $1,819.70 | $2,454.71 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $2,137.96 / $2,691.53
| Professional | | $457.09 | $2,137.96 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $3,019.95 / $3,548.13
| Facility | | $416.87 | $3,019.95 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $2,754.23 / $2,754.23
| Professional | | $208.93 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,025.60 / $8,317.64
| Facility | | $4,265.80 | $6,025.60 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $15,488.17 / $15,488.17
| Professional | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,162.28 / $21,379.62
| Professional | | $2,454.71 | $3,162.28 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $5,888.44
| Professional | | $2,754.23 | $3,715.35 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,754.23
| Facility | | $2,454.71 | $2,454.71 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $3,801.89
| Professional | | $1,148.15 | $1,659.59 | $3,801.89 |