- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,162.28 / $6,456.54
| Facility | | $1,288.25 | $3,162.28 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,344.23 / $4,365.16
| Professional | | $1,949.84 | $2,344.23 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $9,549.93 / $15,135.61
| Facility | | $5,011.87 | $9,549.93 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,090.30 / $4,897.79
| Professional | | $2,238.72 | $3,090.30 | $4,897.79 |
- 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
- $2,041.74 / $2,818.38 / $4,365.16
| Professional | | $2,041.74 | $2,818.38 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $23,442.29 / $23,442.29
| Facility | | $5,011.87 | $23,442.29 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,595.87 / $20,892.96 / $20,892.96
| Professional | | $16,595.87 | $20,892.96 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,232.93 / $19,952.62
| Facility | | $6,456.54 | $10,232.93 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $4,265.80
| Professional | | $1,778.28 | $2,398.83 | $4,265.80 |