- 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
- $1,621.81 / $2,238.72 / $3,019.95
| Professional | | $1,621.81 | $2,238.72 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $3,548.13
| Professional | | $1,659.59 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,479.11 / $5,623.41
| Facility | | $54.95 | $1,479.11 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $13,182.57
| Professional | | $1,659.59 | $2,187.76 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $5,623.41
| Facility | | $912.01 | $1,445.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $2,951.21
| Professional | | $1,659.59 | $2,187.76 | $2,951.21 |