- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $4,365.16
| Facility | | $933.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,584.89 / $2,454.71
| Professional | | $1,174.90 | $1,584.89 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $2,344.23
| Professional | | $1,513.56 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $1,318.26
| Facility | | $39.81 | $39.81 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $2,454.71
| Professional | | $1,148.15 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $7,413.10 / $18,197.01
| Facility | | $1,202.26 | $7,413.10 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,479.11 / $2,754.23
| Professional | | $1,148.15 | $1,479.11 | $2,754.23 |