- 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
- $3,388.44 / $4,073.80 / $6,309.57
| Professional | | $3,388.44 | $4,073.80 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,570.88 / $7,762.47
| Professional | | $2,238.72 | $4,570.88 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $4,168.69 / $6,309.57
| Facility | | $851.14 | $4,168.69 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,897.79 / $26,915.35
| Professional | | $3,467.37 | $4,897.79 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $5,623.41
| Facility | | $776.25 | $1,230.27 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,466.84 / $6,606.93
| Professional | | $3,235.94 | $4,466.84 | $6,606.93 |