- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,897.79 / $9,772.37
| Facility | | $2,398.83 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,479.11 / $3,801.89
| Professional | | $812.83 | $1,479.11 | $3,801.89 |
- 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
- $1,148.15 / $2,630.27 / $3,801.89
| Professional | | $1,148.15 | $2,630.27 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,951.21 / $3,630.78
| Professional | | $1,862.09 | $2,951.21 | $3,630.78 |
- 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 / $2,290.87 / $3,548.13
| Professional | | $1,348.96 | $2,290.87 | $3,548.13 |
- 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
- $1,659.59 / $2,290.87 / $4,466.84
| Professional | | $1,659.59 | $2,290.87 | $4,466.84 |