- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,623.41 / $10,471.29
| Facility | | $3,090.30 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $3,981.07
| Professional | | $2,187.76 | $2,570.40 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,311.31 / $5,011.87
| Professional | | $2,238.72 | $3,311.31 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,570.40 / $4,897.79
| Facility | | $54.95 | $2,570.40 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $18,197.01
| Professional | | $2,290.87 | $2,818.38 | $18,197.01 |
- 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
- $2,238.72 / $2,754.23 / $3,981.07
| Professional | | $2,238.72 | $2,754.23 | $3,981.07 |