- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,623.41 / $10,471.29
| Facility | | $2,344.23 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,344.23
| Professional | | $1,230.27 | $1,737.80 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,041.74 / $3,019.95
| Professional | | $1,445.44 | $2,041.74 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,949.84 / $5,623.41
| Facility | | $54.95 | $1,949.84 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,819.70 / $16,982.44
| Professional | | $1,412.54 | $1,819.70 | $16,982.44 |
- 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
- $1,445.44 / $1,819.70 / $2,454.71
| Professional | | $1,445.44 | $1,819.70 | $2,454.71 |