- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,623.41 / $10,471.29
| Facility | | $1,995.26 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $2,290.87
| Professional | | $1,047.13 | $1,479.11 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,778.28 / $2,454.71
| Professional | | $1,318.26 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,737.80 / $4,897.79
| Facility | | $54.95 | $1,737.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $10,232.93
| Professional | | $1,202.26 | $1,513.56 | $10,232.93 |
- 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
- $1,202.26 / $1,513.56 / $2,041.74
| Professional | | $1,202.26 | $1,513.56 | $2,041.74 |