- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,578.48 / $2,915.41 / $9,385.69
| Facility | | $2,578.48 | $2,915.41 | $9,385.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.48 / $2,681.63 / $3,059.81
| Professional | | $2,578.48 | $2,681.63 | $3,059.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.75 / $4,538.13 / $6,772.82
| Professional | | $1,787.75 | $4,538.13 | $6,772.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,268.21 / $4,125.58 / $15,282.64
| Facility | | $2,268.21 | $4,125.58 | $15,282.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,437.98 / $3,437.98 / $16,571.06
| Professional | | $3,437.98 | $3,437.98 | $16,571.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,982.09 / $16,330.41 / $16,330.41
| Facility | | $5,982.09 | $16,330.41 | $16,330.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,121.14 / $17,121.14 / $25,784.85
| Professional | | $17,121.14 | $17,121.14 | $25,784.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,062.79 / $2,062.79 / $3,437.98
| Facility | | $2,062.79 | $2,062.79 | $3,437.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.95 / $2,062.79 / $3,437.98
| Professional | | $1,443.95 | $2,062.79 | $3,437.98 |