- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,754.40 / $9,772.37
| Facility | | $2,398.83 | $5,754.40 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,630.27 / $4,466.84
| Professional | | $1,513.56 | $2,630.27 | $4,466.84 |
- 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
- $2,137.96 / $5,011.87 / $7,244.36
| Professional | | $2,137.96 | $5,011.87 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,025.60 / $7,079.46
| Professional | | $4,265.80 | $6,025.60 | $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
- $2,398.83 / $4,365.16 / $6,760.83
| Professional | | $2,398.83 | $4,365.16 | $6,760.83 |
- 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
- $2,137.96 / $4,365.16 / $8,317.64
| Professional | | $2,137.96 | $4,365.16 | $8,317.64 |