- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,623.41 / $10,471.29
| Facility | | $2,187.76 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $2,187.76
| Professional | | $1,148.15 | $1,621.81 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $2,754.23
| Professional | | $1,445.44 | $1,905.46 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,905.46 / $4,897.79
| Facility | | $54.95 | $1,905.46 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $10,471.29
| Professional | | $1,318.26 | $1,737.80 | $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
- $1,380.38 / $1,778.28 / $2,290.87
| Professional | | $1,380.38 | $1,778.28 | $2,290.87 |