- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $9,120.11 / $16,595.87
| Facility | | $1,737.80 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $3,019.95
| Professional | | $1,380.38 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $14,454.40 / $24,547.09
| Facility | | $7,585.78 | $14,454.40 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,290.87 / $3,801.89
| Facility | | $1,737.80 | $2,290.87 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,513.56
| Professional | | $1,479.11 | $1,479.11 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $11,220.18 / $16,982.44
| Facility | | $2,754.23 | $11,220.18 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $3,630.78
| Professional | | $1,548.82 | $2,187.76 | $3,630.78 |