- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,309.57 / $9,772.37
| Facility | | $2,398.83 | $6,309.57 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,905.46 / $4,897.79
| Professional | | $1,047.13 | $1,905.46 | $4,897.79 |
- 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
- $1,445.44 / $3,388.44 / $4,897.79
| Professional | | $1,445.44 | $3,388.44 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,715.35 / $4,570.88
| Professional | | $2,344.23 | $3,715.35 | $4,570.88 |
- 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
- $1,698.24 / $2,951.21 / $4,570.88
| Professional | | $1,698.24 | $2,951.21 | $4,570.88 |
- 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
- $2,089.30 / $2,951.21 / $5,623.41
| Professional | | $2,089.30 | $2,951.21 | $5,623.41 |