- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,606.93 / $9,772.37
| Facility | | $2,398.83 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $5,128.61
| Professional | | $1,659.59 | $1,949.84 | $5,128.61 |
- 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
- $1,621.81 / $3,715.35 / $5,248.07
| Professional | | $1,621.81 | $3,715.35 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,073.80 / $5,011.87
| Professional | | $2,570.40 | $4,073.80 | $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
- $1,905.46 / $3,235.94 / $5,011.87
| Professional | | $1,905.46 | $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
- $2,290.87 / $3,235.94 / $6,309.57
| Professional | | $2,290.87 | $3,235.94 | $6,309.57 |