- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $6,025.60
| Facility | | $2,187.76 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,584.89 / $2,818.38
| Professional | | $1,380.38 | $1,584.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,995.26 / $2,344.23
| Professional | | $1,905.46 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $4,265.80
| Professional | | $32.36 | $33.11 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,090.30 / $3,311.31
| Professional | | $1,819.70 | $3,090.30 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,311.31 / $4,466.84
| Professional | | $1,318.26 | $3,311.31 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,238.72 / $2,691.53
| Professional | | $1,949.84 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,128.61 / $13,803.84
| Facility | | $2,290.87 | $5,128.61 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $2,951.21
| Professional | | $1,380.38 | $1,819.70 | $2,951.21 |