- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,623.41 / $10,471.29
| Facility | | $3,090.30 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $3,090.30
| Professional | | $1,621.81 | $2,290.87 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Professional | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,691.53 / $4,073.80
| Professional | | $2,041.74 | $2,691.53 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,454.71 / $5,623.41
| Facility | | $54.95 | $2,454.71 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $24,547.09
| Professional | | $1,862.09 | $2,344.23 | $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
- $1,949.84 / $2,344.23 / $3,162.28
| Professional | | $1,949.84 | $2,344.23 | $3,162.28 |