- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,585.78 / $9,772.37
| Facility | | $2,398.83 | $7,585.78 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,344.23 / $5,754.40
| Professional | | $1,318.26 | $2,344.23 | $5,754.40 |
- 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
- $1,905.46 / $4,365.16 / $6,309.57
| Professional | | $1,905.46 | $4,365.16 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,786.30 / $6,025.60
| Professional | | $3,090.30 | $4,786.30 | $6,025.60 |
- 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
- $2,187.76 / $3,890.45 / $5,888.44
| Professional | | $2,187.76 | $3,890.45 | $5,888.44 |
- 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
- $2,691.53 / $3,801.89 / $7,413.10
| Professional | | $2,691.53 | $3,801.89 | $7,413.10 |