- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,623.41 / $10,471.29
| Facility | | $3,019.95 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,238.72 / $3,548.13
| Professional | | $1,584.89 | $2,238.72 | $3,548.13 |
- 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
- $1,949.84 / $2,691.53 / $4,073.80
| Professional | | $1,949.84 | $2,691.53 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,454.71 / $5,011.87
| Facility | | $54.95 | $2,454.71 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,398.83 / $22,387.21
| Professional | | $1,862.09 | $2,398.83 | $22,387.21 |
- 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
- $1,905.46 / $2,398.83 / $3,235.94
| Professional | | $1,905.46 | $2,398.83 | $3,235.94 |