- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,741.00 / $10,175.36 / $13,413.92
| Facility | | $3,741.00 | $10,175.36 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.02 / $1,330.43 / $7,274.30
| Professional | | $1,140.02 | $1,330.43 | $7,274.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,581.23 / $2,581.23 / $4,997.46
| Professional | | $2,581.23 | $2,581.23 | $4,997.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,274.30 / $10,184.02 / $10,402.25
| Facility | | $7,274.30 | $10,184.02 | $10,402.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,299.11 / $3,929.60 / $4,398.81
| Professional | | $3,299.11 | $3,929.60 | $4,398.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,257.75 / $5,666.25 / $6,572.85
| Professional | | $3,257.75 | $5,666.25 | $6,572.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,274.30 / $10,184.02 / $10,402.25
| Facility | | $7,274.30 | $10,184.02 | $10,402.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.83 / $4,439.87 / $9,953.45
| Professional | | $2,064.83 | $4,439.87 | $9,953.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.17 / $3,997.98 / $6,031.37
| Professional | | $1,657.17 | $3,997.98 | $6,031.37 |