- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,466.84 / $7,079.46
| Facility | | $1,659.59 | $4,466.84 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $2,630.27
| Professional | | $1,513.56 | $2,041.74 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,754.23 / $3,235.94
| Facility | | $602.56 | $2,754.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $2,511.89 / $2,511.89
| Professional | | $302.00 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,495.41 / $7,585.78
| Facility | | $3,890.45 | $5,495.41 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $6,025.60 / $14,125.38
| Professional | | $1,258.93 | $6,025.60 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,884.03 / $6,309.57
| Professional | | $2,511.89 | $2,884.03 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,090.30 / $4,677.35
| Professional | | $2,454.71 | $3,090.30 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,511.89
| Facility | | $2,238.72 | $2,238.72 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $3,467.37
| Professional | | $1,047.13 | $1,513.56 | $3,467.37 |