- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,623.41 / $10,471.29
| Facility | | $2,454.71 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $2,454.71
| Professional | | $1,258.93 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $3,019.95
| Professional | | $1,584.89 | $2,137.96 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,949.84 / $4,897.79
| Facility | | $54.95 | $1,949.84 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,905.46 / $10,471.29
| Professional | | $1,479.11 | $1,905.46 | $10,471.29 |
- 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
- $1,513.56 / $1,905.46 / $2,454.71
| Professional | | $1,513.56 | $1,905.46 | $2,454.71 |