- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,786.30 / $9,772.37
| Facility | | $2,187.76 | $4,786.30 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $3,715.35
| Professional | | $1,258.93 | $1,548.82 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,715.19 / $16,595.87
| Facility | | $3,890.45 | $10,715.19 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,884.03 / $4,168.69
| Professional | | $1,318.26 | $2,884.03 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $2,454.71 / $4,786.30
| Professional | | $467.74 | $2,454.71 | $4,786.30 |
- 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
- $1,513.56 / $2,454.71 / $4,168.69
| Professional | | $1,513.56 | $2,454.71 | $4,168.69 |
- 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
- $1,513.56 / $2,398.83 / $4,168.69
| Professional | | $1,513.56 | $2,398.83 | $4,168.69 |