- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,456.54 / $18,620.87
| Facility | | $3,162.28 | $6,456.54 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $4,365.16
| Professional | | $2,290.87 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $5,495.41
| Professional | | $2,884.03 | $3,801.89 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $3,090.30 / $5,128.61
| Facility | | $54.95 | $3,090.30 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $19,952.62
| Professional | | $2,398.83 | $3,019.95 | $19,952.62 |
- 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
- $2,041.74 / $3,090.30 / $4,466.84
| Professional | | $2,041.74 | $3,090.30 | $4,466.84 |