- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,762.47 / $9,772.37
| Facility | | $2,398.83 | $7,762.47 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,187.76 / $6,025.60
| Professional | | $1,230.27 | $2,187.76 | $6,025.60 |
- 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
- $1,737.80 / $4,073.80 / $5,888.44
| Professional | | $1,737.80 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,466.84 / $5,495.41
| Professional | | $2,818.38 | $4,466.84 | $5,495.41 |
- 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
- $2,041.74 / $3,548.13 / $5,370.32
| Professional | | $2,041.74 | $3,548.13 | $5,370.32 |
- 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
- $2,630.27 / $3,548.13 / $6,760.83
| Professional | | $2,630.27 | $3,548.13 | $6,760.83 |