- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $15,848.93 / $20,417.38
| Facility | | $2,884.03 | $15,848.93 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,884.03 / $4,073.80
| Professional | | $1,778.28 | $2,884.03 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,818.38 / $8,912.51
| Facility | | $2,754.23 | $2,818.38 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,890.45 / $15,135.61
| Facility | | $2,754.23 | $3,890.45 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,019.95 / $3,715.35
| Professional | | $2,754.23 | $3,019.95 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $9,332.54
| Professional | | $2,290.87 | $2,290.87 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,884.03 / $4,897.79
| Professional | | $2,570.40 | $2,884.03 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,949.84
| Professional | | $1,348.96 | $1,348.96 | $1,949.84 |