- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $7,585.78
| Facility | | $2,398.83 | $2,691.53 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,659.59 / $3,235.94
| Professional | | $1,412.54 | $1,659.59 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,511.89 / $6,309.57
| Facility | | $1,348.96 | $2,511.89 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,290.87 / $3,548.13
| Professional | | $1,659.59 | $2,290.87 | $3,548.13 |
- 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
- $1,445.44 / $1,949.84 / $3,162.28
| Professional | | $1,445.44 | $1,949.84 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $16,218.10 / $16,218.10
| Facility | | $5,011.87 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $14,454.40 / $14,454.40
| Professional | | $11,220.18 | $14,454.40 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,630.27 / $4,786.30
| Facility | | $1,258.93 | $2,630.27 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,819.70 / $3,019.95
| Professional | | $1,318.26 | $1,819.70 | $3,019.95 |