- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,388.44 / $6,025.60
| Facility | | $2,454.71 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $2,818.38
| Professional | | $1,412.54 | $1,698.24 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,137.96 / $2,398.83
| Professional | | $1,995.26 | $2,137.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $4,570.88
| Professional | | $32.36 | $33.11 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,311.31 / $4,365.16
| Professional | | $1,862.09 | $3,311.31 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,388.44 / $4,677.35
| Professional | | $1,288.25 | $3,388.44 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $3,388.44
| Professional | | $1,862.09 | $2,290.87 | $3,388.44 |
- 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
- $1,412.54 / $1,862.09 / $3,090.30
| Professional | | $1,412.54 | $1,862.09 | $3,090.30 |