- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,623.41 / $10,471.29
| Facility | | $2,754.23 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $3,311.31
| Professional | | $1,621.81 | $2,137.96 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,630.78 / $5,754.40
| Facility | | $2,754.23 | $3,630.78 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,344.23 / $3,630.78
| Professional | | $1,548.82 | $2,344.23 | $3,630.78 |
- 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
- $1,737.80 / $2,089.30 / $13,182.57
| Professional | | $1,737.80 | $2,089.30 | $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
- $1,737.80 / $2,041.74 / $3,090.30
| Professional | | $1,737.80 | $2,041.74 | $3,090.30 |