- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,623.41 / $10,471.29
| Facility | | $3,162.28 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,691.53 / $3,630.78
| Professional | | $1,905.46 | $2,691.53 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,162.28 / $4,786.30
| Professional | | $2,398.83 | $3,162.28 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,691.53 / $5,623.41
| Facility | | $54.95 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $24,547.09
| Professional | | $2,187.76 | $2,691.53 | $24,547.09 |
- 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
- $2,238.72 / $2,691.53 / $3,715.35
| Professional | | $2,238.72 | $2,691.53 | $3,715.35 |