- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,623.41 / $10,471.29
| Facility | | $2,089.30 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $2,089.30
| Professional | | $1,096.48 | $1,548.82 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $2,570.40
| Professional | | $1,380.38 | $1,819.70 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,778.28 / $4,897.79
| Facility | | $54.95 | $1,778.28 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $8,912.51
| Professional | | $1,288.25 | $1,548.82 | $8,912.51 |
- 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
- $1,288.25 / $1,584.89 / $2,137.96
| Professional | | $1,288.25 | $1,584.89 | $2,137.96 |