- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,623.41 / $10,471.29
| Facility | | $2,754.23 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $2,754.23
| Professional | | $1,513.56 | $2,041.74 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Professional | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $3,630.78
| Professional | | $1,819.70 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,041.74 / $4,897.79
| Facility | | $54.95 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $16,595.87
| Professional | | $1,698.24 | $2,187.76 | $16,595.87 |
- 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
- $1,737.80 / $2,187.76 / $2,951.21
| Professional | | $1,737.80 | $2,187.76 | $2,951.21 |