- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,244.36 / $9,772.37
| Facility | | $2,398.83 | $7,244.36 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,995.26 / $5,623.41
| Professional | | $1,202.26 | $1,995.26 | $5,623.41 |
- 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
- $1,621.81 / $3,715.35 / $5,370.32
| Professional | | $1,621.81 | $3,715.35 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,168.69 / $5,128.61
| Professional | | $2,630.27 | $4,168.69 | $5,128.61 |
- 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
- $1,905.46 / $3,235.94 / $5,011.87
| Professional | | $1,905.46 | $3,235.94 | $5,011.87 |
- 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
- $2,398.83 / $3,235.94 / $6,309.57
| Professional | | $2,398.83 | $3,235.94 | $6,309.57 |