- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,388.44 / $6,025.60
| Facility | | $1,380.38 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $933.25 / $1,778.28
| Professional | | $794.33 | $933.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,230.27 / $1,513.56
| Professional | | $1,122.02 | $1,230.27 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $60.26 / $4,466.84
| Professional | | $32.36 | $60.26 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,905.46 / $2,041.74
| Professional | | $1,047.13 | $1,905.46 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,905.46 / $2,630.27
| Professional | | $741.31 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,288.25 / $4,168.69
| Professional | | $1,122.02 | $1,288.25 | $4,168.69 |
- 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
- $794.33 / $1,071.52 / $1,737.80
| Professional | | $794.33 | $1,071.52 | $1,737.80 |