- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $6,760.83 / $13,182.57
| Facility | | $1,905.46 | $6,760.83 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $2,137.96 / $2,570.40
| Professional | | $457.09 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,951.21 / $3,890.45
| Professional | | $2,754.23 | $2,951.21 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $6,918.31 / $15,848.93
| Facility | | $1,778.28 | $6,918.31 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $5,011.87
| Facility | | $2,041.74 | $2,454.71 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,754.23 / $3,311.31
| Facility | | $2,454.71 | $2,754.23 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $2,754.23
| Professional | | $1,148.15 | $1,659.59 | $2,754.23 |