- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,623.41 / $10,471.29
| Facility | | $3,162.28 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $3,548.13
| Professional | | $1,862.09 | $2,630.27 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,951.21 / $4,265.80
| Professional | | $1,995.26 | $2,951.21 | $4,265.80 |
- 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
- $1,659.59 / $2,290.87 / $15,135.61
| Professional | | $1,659.59 | $2,290.87 | $15,135.61 |
- 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
- $1,659.59 / $2,290.87 / $3,630.78
| Professional | | $1,659.59 | $2,290.87 | $3,630.78 |