- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,623.41 / $10,471.29
| Facility | | $2,691.53 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $3,630.78
| Professional | | $1,905.46 | $2,290.87 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $4,265.80
| Professional | | $1,862.09 | $2,630.27 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,238.72 / $4,897.79
| Facility | | $54.95 | $2,238.72 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $15,135.61
| Professional | | $1,995.26 | $2,344.23 | $15,135.61 |
- 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 / $2,344.23 / $3,235.94
| Professional | | $1,949.84 | $2,344.23 | $3,235.94 |