- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,818.38 / $4,365.16
| Facility | | $933.25 | $2,818.38 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,862.09 / $3,019.95
| Professional | | $1,621.81 | $1,862.09 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,754.40 / $10,471.29
| Facility | | $2,630.27 | $5,754.40 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,454.71 / $3,090.30
| Professional | | $1,995.26 | $2,454.71 | $3,090.30 |
- 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
- $1,445.44 / $2,187.76 / $3,235.94
| Professional | | $1,445.44 | $2,187.76 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,786.30 / $10,964.78
| Facility | | $1,148.15 | $4,786.30 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $3,890.45
| Professional | | $1,548.82 | $2,187.76 | $3,890.45 |