- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $12,022.64 / $16,595.87
| Facility | | $3,630.78 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,445.44 / $3,630.78
| Professional | | $1,122.02 | $1,445.44 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $3,981.07
| Professional | | $1,202.26 | $1,698.24 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,698.24 / $4,677.35
| Facility | | $1,174.90 | $1,698.24 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,981.07 / $7,585.78
| Professional | | $2,818.38 | $3,981.07 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,011.87 / $7,079.46
| Professional | | $2,754.23 | $5,011.87 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,819.70 / $4,677.35
| Facility | | $1,122.02 | $1,819.70 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,819.70 / $3,981.07
| Professional | | $60.26 | $1,819.70 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,235.94 / $7,762.47
| Professional | | $1,148.15 | $3,235.94 | $7,762.47 |