- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,495.41 / $9,772.37
| Facility | | $2,398.83 | $5,495.41 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,659.59 / $4,265.80
| Professional | | $954.99 | $1,659.59 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,772.37 / $15,135.61
| Facility | | $5,495.41 | $9,772.37 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,818.38 / $4,073.80
| Professional | | $1,230.27 | $2,818.38 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,548.13 / $4,365.16
| Professional | | $1,995.26 | $3,548.13 | $4,365.16 |
- 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
- $1,445.44 / $2,454.71 / $3,801.89
| Professional | | $1,445.44 | $2,454.71 | $3,801.89 |
- 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
- $1,995.26 / $2,570.40 / $4,897.79
| Professional | | $1,995.26 | $2,570.40 | $4,897.79 |