- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,388.44 / $6,025.60
| Facility | | $1,862.09 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,187.76
| Professional | | $1,862.09 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $537.03 / $741.31
| Professional | | $389.05 | $537.03 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $79.43
| Professional | | $30.20 | $44.67 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- 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
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |