- 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
- $1,659.59 / $2,344.23 / $3,090.30
| Professional | | $1,659.59 | $2,344.23 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Professional | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $4,073.80
| Professional | | $2,041.74 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,570.40 / $5,011.87
| Facility | | $54.95 | $2,570.40 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,511.89 / $13,182.57
| Professional | | $1,949.84 | $2,511.89 | $13,182.57 |
- 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
- $1,995.26 / $2,570.40 / $3,388.44
| Professional | | $1,995.26 | $2,570.40 | $3,388.44 |