- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $4,365.16
| Facility | | $933.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $2,511.89
| Professional | | $1,548.82 | $1,905.46 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $18,197.01 / $25,118.86
| Facility | | $10,715.19 | $18,197.01 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $2,884.03
| Professional | | $1,862.09 | $2,290.87 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,137.96 / $2,951.21
| Professional | | $1,412.54 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,230.27 / $6,165.95
| Facility | | $389.05 | $1,230.27 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $3,467.37
| Professional | | $1,479.11 | $2,187.76 | $3,467.37 |