- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,309.57 / $9,772.37
| Facility | | $2,398.83 | $6,309.57 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,862.09 / $4,897.79
| Professional | | $1,096.48 | $1,862.09 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $12,022.64 / $22,908.68
| Facility | | $10,964.78 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,548.13 / $5,128.61
| Professional | | $1,584.89 | $3,548.13 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,890.45 / $4,786.30
| Professional | | $2,511.89 | $3,890.45 | $4,786.30 |
- 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
- $1,819.70 / $3,235.94 / $5,011.87
| Professional | | $1,819.70 | $3,235.94 | $5,011.87 |
- 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
- $2,238.72 / $3,090.30 / $6,165.95
| Professional | | $2,238.72 | $3,090.30 | $6,165.95 |