- 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
- $741.31 / $891.25 / $3,162.28
| Professional | | $741.31 | $891.25 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $2,630.27
| Professional | | $812.83 | $1,174.90 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $1,479.11
| Professional | | $812.83 | $1,071.52 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,964.78 / $16,595.87
| Facility | | $6,606.93 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,096.48 / $3,388.44
| Professional | | $776.25 | $1,096.48 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,585.78 / $15,135.61
| Facility | | $3,630.78 | $7,585.78 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $933.25 / $2,137.96
| Professional | | $676.08 | $933.25 | $2,137.96 |