- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $12,882.50
| Facility | | $2,570.40 | $3,467.37 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,162.28 / $4,073.80
| Professional | | $2,570.40 | $3,162.28 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,168.69 / $5,011.87
| Facility | | $2,511.89 | $4,168.69 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $3,890.45
| Professional | | $1,258.93 | $1,258.93 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $8,511.38 / $11,748.98
| Facility | | $6,025.60 | $8,511.38 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $19,952.62
| Professional | | $2,290.87 | $2,290.87 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,011.87 / $17,782.79
| Professional | | $3,467.37 | $5,011.87 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,248.07 / $8,317.64
| Professional | | $3,890.45 | $5,248.07 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,467.37 / $3,890.45
| Facility | | $3,388.44 | $3,467.37 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $5,370.32
| Professional | | $1,621.81 | $2,344.23 | $5,370.32 |