- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,623.41 / $12,302.69
| Facility | | $2,041.74 | $5,623.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $1,862.09
| Professional | | $812.83 | $1,047.13 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,548.13 / $3,548.13
| Facility | | $3,311.31 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,122.02 / $1,548.82
| Professional | | $812.83 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,698.24 / $26,302.68
| Facility | | $977.24 | $1,698.24 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $6,606.93
| Professional | | $812.83 | $977.24 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,019.95 / $4,677.35
| Facility | | $1,513.56 | $3,019.95 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $977.24 / $1,479.11
| Professional | | $776.25 | $977.24 | $1,479.11 |