- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,760.83 / $9,772.37
| Facility | | $2,398.83 | $6,760.83 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,089.30 / $4,073.80
| Professional | | $1,778.28 | $2,089.30 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,964.78 / $16,982.44
| Facility | | $3,890.45 | $10,964.78 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,890.45 / $5,754.40
| Professional | | $1,862.09 | $3,890.45 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $2,951.21 / $5,370.32
| Professional | | $691.83 | $2,951.21 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $3,388.44 / $7,413.10
| Facility | | $446.68 | $3,388.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $4,897.79
| Professional | | $2,137.96 | $3,019.95 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $3,388.44 / $7,413.10
| Facility | | $446.68 | $3,388.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,019.95 / $5,370.32
| Professional | | $2,041.74 | $3,019.95 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,995.26 / $2,454.71
| Facility | | $1,445.44 | $1,995.26 | $2,454.71 |