- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,265.80 / $9,772.37
| Facility | | $2,398.83 | $4,265.80 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $2,951.21
| Professional | | $1,202.26 | $1,412.54 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $19,952.62 / $30,902.95
| Facility | | $5,623.41 | $19,952.62 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,454.71 / $3,467.37
| Professional | | $1,122.02 | $2,454.71 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $3,715.35
| Professional | | $1,479.11 | $2,089.30 | $3,715.35 |
- 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
- $1,318.26 / $1,949.84 / $2,951.21
| Professional | | $1,318.26 | $1,949.84 | $2,951.21 |
- 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
- $1,318.26 / $1,819.70 / $3,467.37
| Professional | | $1,318.26 | $1,819.70 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,513.56
| Facility | | $933.25 | $933.25 | $1,513.56 |