- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,248.07 / $8,511.38
| Facility | | $2,454.71 | $5,248.07 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,202.26 / $1,995.26
| Professional | | $660.69 | $1,202.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,202.26 / $1,949.84
| Professional | | $371.54 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $2,187.76 / $15,135.61
| Facility | | $676.08 | $2,187.76 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,905.46 / $7,943.28
| Professional | | $1,230.27 | $1,905.46 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $5,754.40
| Facility | | $2,137.96 | $3,019.95 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,819.70 / $2,691.53
| Professional | | $1,202.26 | $1,819.70 | $2,691.53 |