- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,623.41 / $10,471.29
| Facility | | $3,162.28 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,235.94
| Professional | | $1,778.28 | $2,398.83 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,630.27 / $3,801.89
| Professional | | $1,698.24 | $2,630.27 | $3,801.89 |
- 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
- $1,621.81 / $2,089.30 / $15,135.61
| Professional | | $1,621.81 | $2,089.30 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,778.28 / $5,623.41
| Facility | | $912.01 | $1,778.28 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $2,951.21
| Professional | | $1,621.81 | $2,137.96 | $2,951.21 |