- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,317.64 / $15,848.93
| Facility | | $4,570.88 | $8,317.64 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $2,951.21
| Professional | | $912.01 | $1,258.93 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $14,454.40 / $16,595.87
| Facility | | $8,317.64 | $14,454.40 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,949.84 / $2,511.89
| Professional | | $1,047.13 | $1,949.84 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,621.81 / $2,511.89
| Professional | | $1,071.52 | $1,621.81 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,862.09
| Professional | | $1,584.89 | $1,584.89 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,471.29 / $16,218.10
| Facility | | $6,456.54 | $10,471.29 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,348.96 / $2,570.40
| Professional | | $933.25 | $1,348.96 | $2,570.40 |