- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,456.54 / $18,620.87
| Facility | | $3,162.28 | $6,456.54 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,238.72 / $3,890.45
| Professional | | $1,949.84 | $2,238.72 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Professional | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,951.21 / $4,570.88
| Professional | | $2,238.72 | $2,951.21 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,090.30 / $10,232.93
| Facility | | $1,862.09 | $3,090.30 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,884.03 / $21,379.62
| Professional | | $2,238.72 | $2,884.03 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $6,918.31 / $18,197.01
| Facility | | $2,884.03 | $6,918.31 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,630.27 / $3,715.35
| Professional | | $2,187.76 | $2,630.27 | $3,715.35 |