- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,623.41 / $10,471.29
| Facility | | $2,570.40 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,137.96 / $3,548.13
| Professional | | $1,737.80 | $2,137.96 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Professional | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,511.89 / $3,890.45
| Professional | | $1,659.59 | $2,511.89 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,344.23 / $4,897.79
| Facility | | $54.95 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $24,547.09
| Professional | | $1,905.46 | $2,238.72 | $24,547.09 |
- 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
- $1,905.46 / $2,187.76 / $3,162.28
| Professional | | $1,905.46 | $2,187.76 | $3,162.28 |