- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $6,025.60
| Facility | | $2,089.30 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,380.38 / $2,818.38
| Professional | | $1,258.93 | $1,380.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,905.46 / $2,137.96
| Professional | | $1,737.80 | $1,905.46 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $3,801.89
| Professional | | $32.36 | $33.11 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,090.30 / $4,466.84
| Professional | | $1,621.81 | $3,090.30 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,290.87 / $3,467.37
| Professional | | $1,148.15 | $2,290.87 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,041.74 / $2,951.21
| Professional | | $1,737.80 | $2,041.74 | $2,951.21 |
- 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
- $1,258.93 / $1,621.81 / $2,630.27
| Professional | | $1,258.93 | $1,621.81 | $2,630.27 |