- 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
- $1,698.24 / $2,041.74 / $3,630.78
| Professional | | $1,698.24 | $2,041.74 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,691.53 / $4,265.80
| Professional | | $1,862.09 | $2,691.53 | $4,265.80 |
- 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
- $1,949.84 / $2,398.83 / $14,125.38
| Professional | | $1,949.84 | $2,398.83 | $14,125.38 |
- 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 / $2,398.83 / $3,388.44
| Professional | | $1,905.46 | $2,398.83 | $3,388.44 |