- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,495.41 / $5,495.41
| Facility | | $3,981.07 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $3,388.44
| Professional | | $1,737.80 | $2,089.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,862.09 / $2,187.76
| Professional | | $1,548.82 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $5,495.41
| Facility | | $1,737.80 | $2,454.71 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $3,981.07
| Professional | | $1,737.80 | $2,089.30 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $77.62
| Professional | | $30.20 | $30.20 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,388.44 / $3,630.78
| Professional | | $3,311.31 | $3,388.44 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $15,488.17 / $26,302.68
| Facility | | $3,715.35 | $15,488.17 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,630.27 / $3,801.89
| Professional | | $2,041.74 | $2,630.27 | $3,801.89 |