- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,335.67 / $5,021.71 / $8,992.37
| Facility | | $2,335.67 | $5,021.71 | $8,992.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.72 / $2,335.67 / $2,394.07
| Professional | | $2,043.72 | $2,335.67 | $2,394.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.83 / $1,401.40 / $3,795.48
| Professional | | $1,167.83 | $1,401.40 | $3,795.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,659.75 / $3,950.42 / $61,041.26
| Facility | | $2,659.75 | $3,950.42 | $61,041.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,659.75 / $3,989.63 / $68,671.42
| Professional | | $2,659.75 | $3,989.63 | $68,671.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,605.60 / $3,006.02 / $16,905.45
| Facility | | $2,605.60 | $3,006.02 | $16,905.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,434.34 / $16,434.34 / $16,434.34
| Professional | | $16,434.34 | $16,434.34 | $16,434.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,605.60 / $3,006.02 / $16,905.45
| Facility | | $2,605.60 | $3,006.02 | $16,905.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $4,709.31
| Professional | | $1,226.23 | $1,751.76 | $4,709.31 |