- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $9,549.93 / $14,125.38
| Facility | | $2,187.76 | $9,549.93 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,995.26 / $13,182.57
| Professional | | $977.24 | $1,995.26 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $6,165.95
| Facility | | $6,165.95 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $3,715.35
| Professional | | $2,454.71 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,949.84 / $2,951.21
| Professional | | $1,318.26 | $1,949.84 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,918.31 / $25,703.96
| Facility | | $6,165.95 | $6,918.31 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $4,168.69
| Professional | | $1,202.26 | $1,905.46 | $4,168.69 |