- 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
- $1,258.93 / $2,290.87 / $5,128.61
| Professional | | $1,258.93 | $2,290.87 | $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
- $1,819.70 / $4,168.69 / $6,025.60
| Professional | | $1,819.70 | $4,168.69 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,570.88 / $5,623.41
| Professional | | $2,884.03 | $4,570.88 | $5,623.41 |
- 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
- $2,089.30 / $3,715.35 / $5,623.41
| Professional | | $2,089.30 | $3,715.35 | $5,623.41 |
- 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
- $2,454.71 / $3,630.78 / $7,079.46
| Professional | | $2,454.71 | $3,630.78 | $7,079.46 |