- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,585.78 / $26,302.68
| Facility | | $5,495.41 | $7,585.78 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,818.38 / $3,019.95
| Professional | | $2,344.23 | $2,818.38 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,951.21 / $8,511.38
| Facility | | $1,584.89 | $2,951.21 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,137.96 / $2,691.53
| Professional | | $1,148.15 | $2,137.96 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,073.80 / $10,471.29
| Facility | | $2,290.87 | $4,073.80 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,073.80 / $5,011.87
| Professional | | $2,818.38 | $4,073.80 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $5,754.40
| Professional | | $3,548.13 | $3,548.13 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $2,398.83
| Facility | | $1,230.27 | $1,230.27 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $4,570.88
| Professional | | $1,479.11 | $2,089.30 | $4,570.88 |