- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,025.60 / $9,772.37
| Facility | | $2,398.83 | $6,025.60 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,778.28 / $4,677.35
| Professional | | $977.24 | $1,778.28 | $4,677.35 |
- 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
- $1,380.38 / $3,235.94 / $4,570.88
| Professional | | $1,380.38 | $3,235.94 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,548.13 / $4,365.16
| Professional | | $2,238.72 | $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
- $1,621.81 / $2,818.38 / $4,265.80
| Professional | | $1,621.81 | $2,818.38 | $4,265.80 |
- 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 / $2,818.38 / $5,370.32
| Professional | | $1,995.26 | $2,818.38 | $5,370.32 |