- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,079.46 / $9,772.37
| Facility | | $2,398.83 | $7,079.46 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,238.72 / $5,495.41
| Professional | | $1,230.27 | $2,238.72 | $5,495.41 |
- 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
- $1,778.28 / $4,073.80 / $5,754.40
| Professional | | $1,778.28 | $4,073.80 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,466.84 / $5,495.41
| Professional | | $2,818.38 | $4,466.84 | $5,495.41 |
- 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
- $2,041.74 / $3,548.13 / $5,495.41
| Professional | | $2,041.74 | $3,548.13 | $5,495.41 |
- 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
- $2,511.89 / $3,548.13 / $6,918.31
| Professional | | $2,511.89 | $3,548.13 | $6,918.31 |