- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $7,762.47 / $14,125.38
| Facility | | $2,290.87 | $7,762.47 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,025.60
| Professional | | $4,897.79 | $4,897.79 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $6,456.54 / $13,489.63
| Facility | | $1,258.93 | $6,456.54 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,897.79 / $6,165.95
| Professional | | $1,230.27 | $4,897.79 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,897.79 / $4,897.79
| Facility | | $2,454.71 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,011.87 / $6,309.57
| Professional | | $4,897.79 | $5,011.87 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $4,897.79
| Facility | | $1,047.13 | $1,513.56 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,897.79 / $5,248.07
| Professional | | $1,584.89 | $4,897.79 | $5,248.07 |