- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $6,025.60
| Facility | | $2,570.40 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $2,818.38
| Professional | | $1,445.44 | $1,698.24 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,187.76 / $2,454.71
| Professional | | $2,041.74 | $2,187.76 | $2,454.71 |
- 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
- $1,905.46 / $3,388.44 / $4,466.84
| Professional | | $1,905.46 | $3,388.44 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,467.37 / $4,786.30
| Professional | | $1,348.96 | $3,467.37 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $3,467.37
| Professional | | $1,949.84 | $2,398.83 | $3,467.37 |
- 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
- $1,479.11 / $1,905.46 / $3,162.28
| Professional | | $1,479.11 | $1,905.46 | $3,162.28 |