- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,623.41 / $10,471.29
| Facility | | $2,884.03 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,454.71 / $3,630.78
| Professional | | $1,995.26 | $2,454.71 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,818.38 / $4,570.88
| Professional | | $1,995.26 | $2,818.38 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,398.83 / $4,897.79
| Facility | | $54.95 | $2,398.83 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $16,218.10
| Professional | | $2,089.30 | $2,511.89 | $16,218.10 |
- 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
- $1,949.84 / $2,454.71 / $3,467.37
| Professional | | $1,949.84 | $2,454.71 | $3,467.37 |