- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,897.79 / $8,511.38
| Facility | | $2,041.74 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $3,548.13
| Professional | | $1,380.38 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $3,311.31
| Professional | | $2,089.30 | $2,238.72 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Professional | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,754.23 / $10,964.78
| Facility | | $1,412.54 | $2,754.23 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $16,982.44
| Professional | | $2,137.96 | $3,019.95 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,818.38 / $10,964.78
| Facility | | $1,380.38 | $2,818.38 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $4,265.80
| Professional | | $2,041.74 | $2,754.23 | $4,265.80 |