- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,025.60 / $10,964.78
| Facility | | $4,570.88 | $6,025.60 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $7,079.46
| Professional | | $2,290.87 | $2,754.23 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,135.61 / $16,595.87
| Facility | | $8,317.64 | $15,135.61 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,011.87 / $7,079.46
| Professional | | $2,511.89 | $5,011.87 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Facility | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,897.79 / $7,079.46
| Professional | | $3,019.95 | $4,897.79 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,073.80 / $5,011.87
| Professional | | $2,238.72 | $4,073.80 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $10,232.93 / $16,218.10
| Facility | | $4,677.35 | $10,232.93 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,981.07 / $6,918.31
| Professional | | $2,290.87 | $3,981.07 | $6,918.31 |