- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,311.31 / $15,135.61
| Facility | | $3,235.94 | $3,311.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $2,511.89
| Professional | | $1,380.38 | $2,041.74 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,495.41 / $5,888.44
| Facility | | $2,454.71 | $5,495.41 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,388.44 / $5,495.41
| Professional | | $2,630.27 | $3,388.44 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $11,481.54 / $25,703.96
| Facility | | $134.90 | $11,481.54 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,511.89
| Professional | | $1,995.26 | $1,995.26 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,511.89 / $5,128.61
| Facility | | $1,174.90 | $2,511.89 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,513.56 / $2,754.23
| Professional | | $1,000.00 | $1,513.56 | $2,754.23 |