- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,309.57 / $10,471.29
| Facility | | $3,162.28 | $6,309.57 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $3,981.07
| Professional | | $2,137.96 | $3,019.95 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,548.13 / $5,128.61
| Professional | | $2,691.53 | $3,548.13 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $3,019.95 / $5,623.41
| Facility | | $54.95 | $3,019.95 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,235.94 / $25,118.86
| Professional | | $2,511.89 | $3,235.94 | $25,118.86 |
- 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
- $2,570.40 / $3,235.94 / $4,365.16
| Professional | | $2,570.40 | $3,235.94 | $4,365.16 |