- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,888.44 / $9,772.37
| Facility | | $2,398.83 | $5,888.44 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,778.28 / $4,570.88
| Professional | | $1,023.29 | $1,778.28 | $4,570.88 |
- 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
- $1,479.11 / $3,388.44 / $4,897.79
| Professional | | $1,479.11 | $3,388.44 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,715.35 / $4,570.88
| Professional | | $2,344.23 | $3,715.35 | $4,570.88 |
- 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
- $1,737.80 / $3,019.95 / $4,677.35
| Professional | | $1,737.80 | $3,019.95 | $4,677.35 |
- 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
- $2,137.96 / $2,951.21 / $5,888.44
| Professional | | $2,137.96 | $2,951.21 | $5,888.44 |