- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $12,302.69
| Facility | | $4,466.84 | $6,918.31 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,090.30 / $5,888.44
| Professional | | $2,570.40 | $3,090.30 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $11,481.54 / $13,803.84
| Professional | | $9,549.93 | $11,481.54 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,168.69 / $5,370.32
| Professional | | $3,090.30 | $4,168.69 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,388.44 / $6,918.31
| Professional | | $2,344.23 | $3,388.44 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,888.44 / $10,471.29
| Facility | | $1,698.24 | $5,888.44 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,951.21 / $5,888.44
| Professional | | $1,949.84 | $2,951.21 | $5,888.44 |