- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,317.64 / $16,218.10
| Facility | | $4,570.88 | $8,317.64 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,412.54 / $3,890.45
| Professional | | $912.01 | $1,412.54 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,168.69 / $12,022.64
| Facility | | $3,715.35 | $4,168.69 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $2,570.40
| Professional | | $977.24 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,754.23
| Professional | | $1,230.27 | $1,737.80 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,621.81 / $1,621.81
| Professional | | $1,584.89 | $1,621.81 | $1,621.81 |
- 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
- $912.01 / $1,584.89 / $2,691.53
| Professional | | $912.01 | $1,584.89 | $2,691.53 |