- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $10,232.93 / $15,848.93
| Facility | | $3,090.30 | $10,232.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $954.99 / $5,754.40
| Professional | | $346.74 | $954.99 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,905.46 / $1,905.46
| Professional | | $1,258.93 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $1,513.56
| Professional | | $741.31 | $1,000.00 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,168.69 / $14,125.38
| Facility | | $2,754.23 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,023.29 / $2,187.76
| Professional | | $660.69 | $1,023.29 | $2,187.76 |