- 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
- $1,479.11 / $2,089.30 / $2,754.23
| Professional | | $1,479.11 | $2,089.30 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $3,548.13
| Professional | | $1,819.70 | $2,454.71 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,089.30 / $4,897.79
| Facility | | $54.95 | $2,089.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $11,748.98
| Professional | | $1,819.70 | $2,344.23 | $11,748.98 |
- 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
- $1,862.09 / $2,344.23 / $3,019.95
| Professional | | $1,862.09 | $2,344.23 | $3,019.95 |