- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,630.78 / $9,772.37
| Facility | | $2,398.83 | $3,630.78 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $2,884.03
| Professional | | $794.33 | $1,096.48 | $2,884.03 |
- 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
- $933.25 / $1,905.46 / $2,754.23
| Professional | | $933.25 | $1,905.46 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,949.84 / $3,019.95
| Professional | | $467.74 | $1,949.84 | $3,019.95 |
- 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
- $1,047.13 / $1,698.24 / $2,951.21
| Professional | | $1,047.13 | $1,698.24 | $2,951.21 |
- 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
- $1,148.15 / $1,737.80 / $3,311.31
| Professional | | $1,148.15 | $1,737.80 | $3,311.31 |