- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,897.79 / $9,772.37
| Facility | | $2,398.83 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,445.44 / $3,801.89
| Professional | | $794.33 | $1,445.44 | $3,801.89 |
- 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
- $1,122.02 / $2,630.27 / $3,801.89
| Professional | | $1,122.02 | $2,630.27 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,884.03 / $3,548.13
| Professional | | $1,819.70 | $2,884.03 | $3,548.13 |
- 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
- $1,318.26 / $2,290.87 / $3,467.37
| Professional | | $1,318.26 | $2,290.87 | $3,467.37 |
- 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
- $1,621.81 / $2,290.87 / $4,365.16
| Professional | | $1,621.81 | $2,290.87 | $4,365.16 |