- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,623.41 / $10,471.29
| Facility | | $2,290.87 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $2,290.87
| Professional | | $1,318.26 | $1,698.24 | $2,290.87 |
- 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
- $1,737.80 / $2,089.30 / $3,311.31
| Professional | | $1,737.80 | $2,089.30 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,089.30 / $4,897.79
| Facility | | $54.95 | $2,089.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,137.96 / $9,549.93
| Professional | | $1,380.38 | $2,137.96 | $9,549.93 |
- 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
- $1,445.44 / $2,137.96 / $2,818.38
| Professional | | $1,445.44 | $2,137.96 | $2,818.38 |