- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,388.44 / $6,025.60
| Facility | | $1,479.11 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,202.26 / $2,818.38
| Professional | | $1,023.29 | $1,202.26 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,445.44 / $2,398.83
| Professional | | $489.78 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $2,398.83
| Professional | | $32.36 | $33.11 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,862.09 / $2,398.83
| Professional | | $1,479.11 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,137.96 / $2,818.38
| Professional | | $1,096.48 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,737.80 / $2,398.83
| Professional | | $1,380.38 | $1,737.80 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,128.61 / $13,803.84
| Facility | | $2,290.87 | $5,128.61 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $1,949.84
| Professional | | $977.24 | $1,230.27 | $1,949.84 |