- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,168.69 / $9,772.37
| Facility | | $2,398.83 | $4,168.69 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,202.26 / $3,162.28
| Professional | | $724.44 | $1,202.26 | $3,162.28 |
- 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
- $933.25 / $2,187.76 / $3,162.28
| Professional | | $933.25 | $2,187.76 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,398.83 / $2,951.21
| Professional | | $1,513.56 | $2,398.83 | $2,951.21 |
- 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
- $1,096.48 / $1,905.46 / $2,884.03
| Professional | | $1,096.48 | $1,905.46 | $2,884.03 |
- 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
- $1,348.96 / $1,905.46 / $3,630.78
| Professional | | $1,348.96 | $1,905.46 | $3,630.78 |