- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,025.60 / $10,471.29
| Facility | | $3,162.28 | $6,025.60 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,884.03 / $3,890.45
| Professional | | $2,041.74 | $2,884.03 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Professional | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $4,897.79
| Professional | | $2,570.40 | $3,388.44 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,884.03 / $5,011.87
| Facility | | $54.95 | $2,884.03 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $22,908.68
| Professional | | $2,290.87 | $2,754.23 | $22,908.68 |
- 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
- $2,290.87 / $2,754.23 / $3,981.07
| Professional | | $2,290.87 | $2,754.23 | $3,981.07 |