- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,365.16 / $9,772.37
| Facility | | $2,398.83 | $4,365.16 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,318.26 / $3,388.44
| Professional | | $794.33 | $1,318.26 | $3,388.44 |
- 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
- $1,122.02 / $2,511.89 / $3,630.78
| Professional | | $1,122.02 | $2,511.89 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,754.23 / $3,388.44
| Professional | | $1,778.28 | $2,754.23 | $3,388.44 |
- 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
- $1,318.26 / $2,290.87 / $3,548.13
| Professional | | $1,318.26 | $2,290.87 | $3,548.13 |
- 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 / $2,187.76 / $4,466.84
| Professional | | $1,584.89 | $2,187.76 | $4,466.84 |