- 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
- $1,513.56 / $2,137.96 / $2,884.03
| Professional | | $1,513.56 | $2,137.96 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,570.40 / $3,630.78
| Professional | | $1,949.84 | $2,570.40 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,290.87 / $5,370.32
| Facility | | $54.95 | $2,290.87 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,290.87 / $21,379.62
| Professional | | $1,778.28 | $2,290.87 | $21,379.62 |
- 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
- $1,819.70 / $2,290.87 / $3,019.95
| Professional | | $1,819.70 | $2,290.87 | $3,019.95 |