- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,248.07 / $7,943.28
| Facility | | $1,995.26 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,698.24 / $3,981.07
| Professional | | $1,096.48 | $1,698.24 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,311.31
| Professional | | $2,691.53 | $2,691.53 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,445.44 / $2,290.87
| Professional | | $831.76 | $1,445.44 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,388.44 / $10,964.78
| Facility | | $1,659.59 | $3,388.44 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,398.83 / $8,511.38
| Professional | | $1,318.26 | $2,398.83 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,691.53 / $3,019.95
| Professional | | $1,905.46 | $2,691.53 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,511.38 / $12,882.50
| Facility | | $5,128.61 | $8,511.38 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,737.80 / $3,235.94
| Professional | | $1,174.90 | $1,737.80 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $2,511.89
| Professional | | $1,698.24 | $2,344.23 | $2,511.89 |