- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,623.41 / $10,471.29
| Facility | | $2,691.53 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,995.26 / $2,691.53
| Professional | | $1,548.82 | $1,995.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,630.78
| Professional | | $1,778.28 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,238.72 / $4,897.79
| Facility | | $54.95 | $2,238.72 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $11,481.54
| Professional | | $1,659.59 | $2,187.76 | $11,481.54 |
- 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
- $1,698.24 / $2,187.76 / $2,951.21
| Professional | | $1,698.24 | $2,187.76 | $2,951.21 |