- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,623.41 / $10,471.29
| Facility | | $3,162.28 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $4,265.80
| Professional | | $2,238.72 | $2,691.53 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,548.13 / $5,495.41
| Professional | | $2,454.71 | $3,548.13 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $3,162.28 / $4,897.79
| Facility | | $54.95 | $3,162.28 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,162.28 / $18,620.87
| Professional | | $2,454.71 | $3,162.28 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $5,623.41
| Facility | | $851.14 | $1,445.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,090.30 / $4,466.84
| Professional | | $2,187.76 | $3,090.30 | $4,466.84 |