- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $8,912.51 / $17,378.01
| Facility | | $2,290.87 | $8,912.51 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $3,630.78
| Professional | | $2,089.30 | $2,570.40 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,691.53 / $13,182.57
| Facility | | $1,819.70 | $2,691.53 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,981.07 / $15,488.17
| Professional | | $2,570.40 | $3,981.07 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,754.23
| Professional | | $1,949.84 | $1,949.84 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $2,884.03
| Professional | | $1,949.84 | $2,630.27 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,884.03 / $3,235.94
| Facility | | $1,348.96 | $2,884.03 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $4,897.79
| Professional | | $1,122.02 | $1,348.96 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,949.84 / $1,949.84
| Professional | | $870.96 | $1,949.84 | $1,949.84 |