- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,888.44 / $10,715.19
| Facility | | $3,388.44 | $5,888.44 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $512.86 / $2,089.30
| Professional | | $354.81 | $512.86 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $537.03 / $1,230.27
| Professional | | $331.13 | $537.03 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $758.58 / $870.96
| Professional | | $562.34 | $758.58 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $10,471.29 / $16,595.87
| Facility | | $6,760.83 | $10,471.29 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $549.54 / $1,000.00
| Professional | | $295.12 | $549.54 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,248.07 / $9,120.11
| Facility | | $2,570.40 | $5,248.07 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $416.87 / $933.25
| Professional | | $251.19 | $416.87 | $933.25 |