- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,495.41 / $9,772.37
| Facility | | $2,398.83 | $5,495.41 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $4,265.80
| Professional | | $1,096.48 | $1,584.89 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $10,471.29 / $19,952.62
| Facility | | $9,332.54 | $10,471.29 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,754.23 / $3,981.07
| Professional | | $1,412.54 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $3,019.95 / $4,265.80
| Professional | | $933.25 | $3,019.95 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,570.40 / $4,365.16
| Professional | | $1,584.89 | $2,570.40 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,511.89 / $4,786.30
| Professional | | $1,621.81 | $2,511.89 | $4,786.30 |