- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,623.41 / $10,471.29
| Facility | | $2,951.21 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $2,951.21
| Professional | | $1,548.82 | $2,187.76 | $2,951.21 |
- 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
- $1,949.84 / $2,630.27 / $3,890.45
| Professional | | $1,949.84 | $2,630.27 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,290.87 / $4,897.79
| Facility | | $54.95 | $2,290.87 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,290.87 / $15,848.93
| Professional | | $1,819.70 | $2,290.87 | $15,848.93 |
- 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
- $1,862.09 / $2,290.87 / $3,019.95
| Professional | | $1,862.09 | $2,290.87 | $3,019.95 |