- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,888.44 / $10,471.29
| Facility | | $3,162.28 | $5,888.44 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $4,570.88
| Professional | | $2,570.40 | $3,235.94 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,630.78 / $5,888.44
| Professional | | $2,570.40 | $3,630.78 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $3,090.30 / $5,011.87
| Facility | | $54.95 | $3,090.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,235.94 / $20,892.96
| Professional | | $2,630.27 | $3,235.94 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $5,623.41
| Facility | | $851.14 | $1,445.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $4,466.84
| Professional | | $2,344.23 | $3,162.28 | $4,466.84 |