- 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
- $831.76 / $1,202.26 / $2,754.23
| Professional | | $831.76 | $1,202.26 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,412.54 / $6,456.54
| Facility | | $891.25 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,311.31 / $5,011.87
| Professional | | $2,344.23 | $3,311.31 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,981.07 / $5,370.32
| Professional | | $3,019.95 | $3,981.07 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,412.54 / $5,011.87
| Facility | | $912.01 | $1,412.54 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $870.96 / $1,995.26
| Professional | | $60.26 | $870.96 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,073.80 / $5,248.07
| Professional | | $1,122.02 | $4,073.80 | $5,248.07 |