- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,570.40 / $6,456.54
| Facility | | $1,096.48 | $2,570.40 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $5,623.41
| Professional | | $2,290.87 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,606.93 / $9,772.37
| Facility | | $2,951.21 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,890.45 / $6,025.60
| Professional | | $2,818.38 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,630.78 / $5,495.41
| Professional | | $2,570.40 | $3,630.78 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $23,442.29 / $23,442.29
| Facility | | $54.95 | $23,442.29 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,542.29 / $27,542.29 / $27,542.29
| Professional | | $27,542.29 | $27,542.29 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $10,232.93
| Facility | | $3,235.94 | $5,754.40 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $5,248.07
| Professional | | $2,290.87 | $3,162.28 | $5,248.07 |