- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $10,232.93 / $28,183.83
| Facility | | $1,862.09 | $10,232.93 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,862.09 / $1,862.09
| Professional | | $1,819.70 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $776.25
| Professional | | $354.81 | $354.81 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $50.12 / $75.86
| Professional | | $32.36 | $50.12 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,311.31 / $37,153.52
| Facility | | $1,122.02 | $3,311.31 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |