- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,786.30 / $9,772.37
| Facility | | $1,737.80 | $4,786.30 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,258.93 / $3,715.35
| Professional | | $1,047.13 | $1,258.93 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $15,488.17 / $24,547.09
| Facility | | $5,623.41 | $15,488.17 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,398.83 / $3,467.37
| Professional | | $1,047.13 | $2,398.83 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $2,238.72 / $3,981.07
| Professional | | $549.54 | $2,238.72 | $3,981.07 |
- 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
- $1,202.26 / $1,949.84 / $3,311.31
| Professional | | $1,202.26 | $1,949.84 | $3,311.31 |
- 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
- $1,258.93 / $1,949.84 / $3,548.13
| Professional | | $1,258.93 | $1,949.84 | $3,548.13 |