- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,623.41 / $10,471.29
| Facility | | $2,951.21 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,238.72 / $2,951.21
| Professional | | $1,584.89 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $3,467.37
| Professional | | $1,949.84 | $2,630.27 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,238.72 / $5,011.87
| Facility | | $54.95 | $2,238.72 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,511.89 / $12,589.25
| Professional | | $1,819.70 | $2,511.89 | $12,589.25 |
- 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
- $1,905.46 / $2,454.71 / $3,311.31
| Professional | | $1,905.46 | $2,454.71 | $3,311.31 |