- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,495.41 / $9,772.37
| Facility | | $2,398.83 | $5,495.41 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $4,168.69
| Professional | | $1,412.54 | $1,737.80 | $4,168.69 |
- 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
- $1,479.11 / $3,235.94 / $4,677.35
| Professional | | $1,479.11 | $3,235.94 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $5,370.32
| Professional | | $933.25 | $2,691.53 | $5,370.32 |
- 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 / $2,691.53 / $4,570.88
| Professional | | $1,659.59 | $2,691.53 | $4,570.88 |
- 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
- $1,621.81 / $2,691.53 / $4,677.35
| Professional | | $1,621.81 | $2,691.53 | $4,677.35 |