- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,388.44 / $6,025.60
| Facility | | $1,513.56 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,230.27 / $2,818.38
| Professional | | $1,023.29 | $1,230.27 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,445.44 / $2,344.23
| Professional | | $676.08 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $60.26
| Professional | | $32.36 | $33.11 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $2,398.83
| Professional | | $1,513.56 | $1,905.46 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,089.30 / $2,884.03
| Professional | | $1,047.13 | $2,089.30 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,659.59 / $2,290.87
| Professional | | $1,318.26 | $1,659.59 | $2,290.87 |
- 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
- $1,000.00 / $1,258.93 / $1,995.26
| Professional | | $1,000.00 | $1,258.93 | $1,995.26 |