- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,162.28 / $11,481.54
| Facility | | $2,398.83 | $3,162.28 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,023.29 / $1,862.09
| Professional | | $831.76 | $1,023.29 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,623.41 / $8,912.51
| Facility | | $5,011.87 | $5,623.41 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,737.80 / $2,454.71
| Professional | | $831.76 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $2,754.23
| Professional | | $1,047.13 | $1,479.11 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,445.44 / $2,187.76
| Professional | | $977.24 | $1,445.44 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $2,630.27
| Professional | | $977.24 | $1,380.38 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $1,096.48
| Facility | | $691.83 | $691.83 | $1,096.48 |