- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,623.41 / $10,471.29
| Facility | | $2,884.03 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $2,884.03
| Professional | | $1,548.82 | $2,187.76 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,570.40 / $3,715.35
| Professional | | $1,949.84 | $2,570.40 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,344.23 / $4,897.79
| Facility | | $54.95 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $12,302.69
| Professional | | $1,778.28 | $2,344.23 | $12,302.69 |
- 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
- $1,862.09 / $2,398.83 / $3,090.30
| Professional | | $1,862.09 | $2,398.83 | $3,090.30 |