- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,388.44 / $6,025.60
| Facility | | $1,659.59 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,202.26 / $2,511.89
| Professional | | $1,023.29 | $1,202.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,584.89 / $2,238.72
| Professional | | $1,023.29 | $1,584.89 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $2,137.96
| Professional | | $32.36 | $33.11 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,187.76 / $2,754.23
| Professional | | $1,412.54 | $2,187.76 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,995.26 / $2,290.87
| Professional | | $954.99 | $1,995.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $2,398.83
| Professional | | $1,412.54 | $1,737.80 | $2,398.83 |
- 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
- $1,047.13 / $1,288.25 / $2,290.87
| Professional | | $1,047.13 | $1,288.25 | $2,290.87 |