- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,248.07 / $7,943.28
| Facility | | $1,202.26 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $1,380.38
| Professional | | $933.25 | $1,258.93 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $3,090.30
| Professional | | $1,548.82 | $1,949.84 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,089.30 / $14,125.38
| Facility | | $1,202.26 | $2,089.30 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,041.74 / $8,709.64
| Professional | | $1,258.93 | $2,041.74 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $3,090.30
| Professional | | $1,548.82 | $1,949.84 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $34,673.69
| Facility | | $8,511.38 | $13,489.63 | $34,673.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,905.46 / $3,630.78
| Professional | | $1,258.93 | $1,905.46 | $3,630.78 |