- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $10,964.78 / $16,595.87
| Facility | | $2,818.38 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,202.26 / $2,818.38
| Professional | | $776.25 | $1,202.26 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,090.30 / $4,073.80
| Professional | | $2,344.23 | $3,090.30 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,584.89 / $6,456.54
| Facility | | $831.76 | $1,584.89 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,235.94 / $4,786.30
| Professional | | $2,187.76 | $3,235.94 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,890.45 / $5,495.41
| Professional | | $3,019.95 | $3,890.45 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,584.89 / $5,011.87
| Facility | | $870.96 | $1,584.89 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,288.25 / $3,090.30
| Professional | | $60.26 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,265.80 / $5,495.41
| Professional | | $1,047.13 | $4,265.80 | $5,495.41 |