- 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
- $2,290.87 / $2,754.23 / $5,495.41
| Professional | | $2,290.87 | $2,754.23 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,244.36 / $11,220.18
| Facility | | $3,801.89 | $7,244.36 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,715.35 / $5,888.44
| Professional | | $2,691.53 | $3,715.35 | $5,888.44 |
- 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
- $2,398.83 / $3,235.94 / $5,248.07
| Professional | | $2,398.83 | $3,235.94 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $32,359.37 / $32,359.37
| Facility | | $5,011.87 | $32,359.37 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,197.01 / $23,442.29 / $23,442.29
| Professional | | $18,197.01 | $23,442.29 | $23,442.29 |
- 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
- $2,187.76 / $3,019.95 / $5,011.87
| Professional | | $2,187.76 | $3,019.95 | $5,011.87 |