- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,309.57 / $10,471.29
| Facility | | $3,162.28 | $6,309.57 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $4,897.79
| Professional | | $2,630.27 | $3,162.28 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Professional | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Professional | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,630.78 / $6,025.60
| Professional | | $1,737.80 | $3,630.78 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,467.37 / $5,011.87
| Facility | | $851.14 | $3,467.37 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,801.89 / $21,877.62
| Professional | | $2,754.23 | $3,801.89 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $5,623.41
| Facility | | $776.25 | $1,230.27 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $5,248.07
| Professional | | $2,570.40 | $3,467.37 | $5,248.07 |