- 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
- $2,754.23 / $3,235.94 / $5,128.61
| Professional | | $2,754.23 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Professional | | $4,466.84 | $4,466.84 | $4,466.84 |
- 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
- $2,290.87 / $3,801.89 / $6,309.57
| Professional | | $2,290.87 | $3,801.89 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,801.89 / $5,370.32
| Facility | | $851.14 | $3,801.89 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,890.45 / $22,387.21
| Professional | | $3,019.95 | $3,890.45 | $22,387.21 |
- 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
- $2,951.21 / $3,548.13 / $5,248.07
| Professional | | $2,951.21 | $3,548.13 | $5,248.07 |