- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,623.41 / $10,471.29
| Facility | | $2,630.27 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $3,467.37
| Professional | | $1,905.46 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Professional | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $2,454.71 / $3,801.89
| Professional | | $446.68 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,570.40 / $4,466.84
| Facility | | $602.56 | $2,570.40 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $15,135.61
| Professional | | $1,862.09 | $2,630.27 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,445.44 / $5,128.61
| Facility | | $776.25 | $1,445.44 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $3,467.37
| Professional | | $1,862.09 | $2,344.23 | $3,467.37 |