- 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
- $2,398.83 / $2,951.21 / $4,265.80
| Professional | | $2,398.83 | $2,951.21 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Professional | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,890.45 / $5,754.40
| Professional | | $2,454.71 | $3,890.45 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $3,162.28 / $5,495.41
| Facility | | $54.95 | $3,162.28 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,388.44 / $21,379.62
| Professional | | $2,691.53 | $3,388.44 | $21,379.62 |
- 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
- $2,691.53 / $3,162.28 / $4,570.88
| Professional | | $2,691.53 | $3,162.28 | $4,570.88 |