- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,623.41 / $10,471.29
| Facility | | $2,884.03 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $3,981.07
| Professional | | $1,905.46 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Professional | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,818.38 / $4,365.16
| Professional | | $1,862.09 | $2,818.38 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,630.27 / $4,897.79
| Facility | | $54.95 | $2,630.27 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,511.89 / $30,199.52
| Professional | | $2,137.96 | $2,511.89 | $30,199.52 |
- 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
- $2,137.96 / $2,398.83 / $3,548.13
| Professional | | $2,137.96 | $2,398.83 | $3,548.13 |