- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $10,964.78
| Facility | | $4,466.84 | $6,918.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $3,235.94
| Professional | | $758.58 | $891.25 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,174.90 / $2,754.23
| Professional | | $794.33 | $1,174.90 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,096.48 / $1,479.11
| Professional | | $1,023.29 | $1,096.48 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,471.29 / $16,595.87
| Facility | | $6,606.93 | $10,471.29 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,148.15 / $3,388.44
| Professional | | $776.25 | $1,148.15 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,606.93 / $10,964.78
| Facility | | $2,951.21 | $6,606.93 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $933.25 / $2,089.30
| Professional | | $676.08 | $933.25 | $2,089.30 |