- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,715.35 / $6,456.54
| Facility | | $2,691.53 | $3,715.35 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $6,760.83
| Professional | | $3,801.89 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $8,317.64 / $22,908.68
| Facility | | $2,570.40 | $8,317.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,918.31 / $15,488.17
| Facility | | $2,570.40 | $6,918.31 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $16,982.44 / $23,988.33
| Professional | | $13,489.63 | $16,982.44 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $8,709.64 / $31,622.78
| Facility | | $3,019.95 | $8,709.64 | $31,622.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $7,244.36 / $16,982.44
| Facility | | $2,570.40 | $7,244.36 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,135.61 / $16,982.44 / $19,952.62
| Professional | | $15,135.61 | $16,982.44 | $19,952.62 |