- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $12,022.64 / $16,595.87
| Facility | | $2,754.23 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,122.02 / $2,754.23
| Professional | | $812.83 | $1,122.02 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,090.30 / $3,890.45
| Professional | | $2,290.87 | $3,090.30 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,258.93 / $6,165.95
| Facility | | $851.14 | $1,258.93 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,818.38 / $5,128.61
| Professional | | $2,187.76 | $2,818.38 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,715.35 / $5,370.32
| Professional | | $2,951.21 | $3,715.35 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $4,786.30
| Facility | | $851.14 | $1,230.27 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,258.93 / $3,090.30
| Professional | | $60.26 | $1,258.93 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,454.71 / $6,165.95
| Professional | | $1,047.13 | $2,454.71 | $6,165.95 |