- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,290.87 / $4,073.80
| Facility | | $758.58 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $1,698.24
| Professional | | $977.24 | $1,380.38 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,943.28 / $13,489.63
| Facility | | $2,454.71 | $7,943.28 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,995.26 / $3,311.31
| Professional | | $1,479.11 | $1,995.26 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Facility | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $12,589.25 / $12,589.25
| Professional | | $11,220.18 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,630.27 / $4,786.30
| Facility | | $1,258.93 | $2,630.27 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $3,019.95
| Professional | | $1,348.96 | $1,905.46 | $3,019.95 |