- 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
- $1,148.15 / $1,905.46 / $5,128.61
| Professional | | $1,148.15 | $1,905.46 | $5,128.61 |
- 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
- $1,479.11 / $3,467.37 / $5,011.87
| Professional | | $1,479.11 | $3,467.37 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,890.45 / $4,677.35
| Professional | | $2,398.83 | $3,890.45 | $4,677.35 |
- 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
- $1,737.80 / $3,019.95 / $4,677.35
| Professional | | $1,737.80 | $3,019.95 | $4,677.35 |
- 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
- $2,137.96 / $3,019.95 / $5,754.40
| Professional | | $2,137.96 | $3,019.95 | $5,754.40 |