- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,079.46 / $9,772.37
| Facility | | $2,398.83 | $7,079.46 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,778.28 / $5,495.41
| Professional | | $1,621.81 | $1,778.28 | $5,495.41 |
- 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
- $1,548.82 / $3,630.78 / $5,248.07
| Professional | | $1,548.82 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $3,311.31 / $5,888.44
| Professional | | $549.54 | $3,311.31 | $5,888.44 |
- 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
- $1,778.28 / $2,884.03 / $4,897.79
| Professional | | $1,778.28 | $2,884.03 | $4,897.79 |
- 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
- $1,862.09 / $2,884.03 / $5,370.32
| Professional | | $1,862.09 | $2,884.03 | $5,370.32 |