- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $10,964.78 / $16,595.87
| Facility | | $2,754.23 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,288.25 / $4,466.84
| Professional | | $724.44 | $1,288.25 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $6,456.54
| Facility | | $831.76 | $831.76 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $3,162.28
| Professional | | $1,905.46 | $2,290.87 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,801.89 / $4,073.80
| Professional | | $2,041.74 | $3,801.89 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,288.25 / $6,456.54
| Facility | | $831.76 | $1,288.25 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,230.27 / $2,951.21
| Professional | | $60.26 | $1,230.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,398.83 / $3,630.78
| Professional | | $1,096.48 | $2,398.83 | $3,630.78 |