- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,623.41 / $10,471.29
| Facility | | $3,019.95 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $3,090.30
| Professional | | $1,513.56 | $1,778.28 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,630.78 / $5,754.40
| Facility | | $2,754.23 | $3,630.78 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- 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
- $1,737.80 / $2,290.87 / $3,467.37
| Professional | | $1,737.80 | $2,290.87 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,454.71 / $8,128.31
| Facility | | $1,445.44 | $2,454.71 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,238.72 / $16,982.44
| Professional | | $1,737.80 | $2,238.72 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $6,025.60 / $12,302.69
| Facility | | $2,754.23 | $6,025.60 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $2,818.38
| Professional | | $1,698.24 | $2,041.74 | $2,818.38 |