- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,623.41 / $10,471.29
| Facility | | $2,454.71 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,041.74 / $3,388.44
| Professional | | $1,659.59 | $2,041.74 | $3,388.44 |
- 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
- $1,584.89 / $2,398.83 / $3,715.35
| Professional | | $1,584.89 | $2,398.83 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,238.72 / $4,897.79
| Facility | | $54.95 | $2,238.72 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,137.96 / $13,182.57
| Professional | | $1,819.70 | $2,137.96 | $13,182.57 |
- 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 / $2,089.30 / $3,019.95
| Professional | | $1,862.09 | $2,089.30 | $3,019.95 |