- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $2,137.96
| Facility | | $1,698.24 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,380.38 / $3,630.78
| Professional | | $912.01 | $1,380.38 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,302.69 / $13,803.84
| Facility | | $7,413.10 | $12,302.69 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,089.30 / $2,754.23
| Professional | | $1,288.25 | $2,089.30 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,949.84 / $2,570.40
| Professional | | $1,412.54 | $1,949.84 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,995.26 / $3,090.30
| Professional | | $1,698.24 | $1,995.26 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,165.95 / $15,135.61
| Facility | | $3,311.31 | $6,165.95 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $2,398.83
| Professional | | $1,148.15 | $1,659.59 | $2,398.83 |