- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,630.27 / $6,456.54
| Facility | | $1,096.48 | $2,630.27 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $6,456.54
| Professional | | $2,754.23 | $3,388.44 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $6,606.93 / $9,772.37
| Facility | | $2,754.23 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,786.30 / $7,585.78
| Professional | | $3,467.37 | $4,786.30 | $7,585.78 |
- 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
- $3,019.95 / $4,365.16 / $6,606.93
| Professional | | $3,019.95 | $4,365.16 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $26,302.68 / $26,302.68
| Facility | | $1,995.26 | $26,302.68 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,442.29 / $28,183.83 / $28,183.83
| Professional | | $23,442.29 | $28,183.83 | $28,183.83 |
- 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
- $2,754.23 / $3,715.35 / $6,456.54
| Professional | | $2,754.23 | $3,715.35 | $6,456.54 |