- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,623.41 / $10,471.29
| Facility | | $2,187.76 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,584.89 / $2,187.76
| Professional | | $1,122.02 | $1,584.89 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $2,818.38
| Professional | | $1,412.54 | $1,905.46 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,819.70 / $4,897.79
| Facility | | $54.95 | $1,819.70 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $12,882.50
| Professional | | $1,318.26 | $1,584.89 | $12,882.50 |
- 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
- $1,318.26 / $1,621.81 / $2,187.76
| Professional | | $1,318.26 | $1,621.81 | $2,187.76 |