- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,623.41 / $10,471.29
| Facility | | $1,949.84 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $1,698.24
| Professional | | $891.25 | $1,258.93 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $2,238.72
| Professional | | $1,122.02 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,290.87 / $13,182.57
| Facility | | $54.95 | $2,290.87 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,288.25 / $10,232.93
| Professional | | $1,023.29 | $1,288.25 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $10,232.93 / $13,803.84
| Facility | | $2,951.21 | $10,232.93 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $1,737.80
| Professional | | $1,071.52 | $1,288.25 | $1,737.80 |