- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $9,772.37 / $9,772.37
| Facility | | $2,398.83 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $7,413.10
| Professional | | $1,698.24 | $2,884.03 | $7,413.10 |
- 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
- $2,238.72 / $5,128.61 / $7,413.10
| Professional | | $2,238.72 | $5,128.61 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,754.40 / $7,079.46
| Professional | | $3,630.78 | $5,754.40 | $7,079.46 |
- 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
- $2,570.40 / $4,466.84 / $6,918.31
| Professional | | $2,570.40 | $4,466.84 | $6,918.31 |
- 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
- $3,235.94 / $4,466.84 / $8,709.64
| Professional | | $3,235.94 | $4,466.84 | $8,709.64 |