- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $11,748.98
| Facility | | $4,466.84 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,174.90
| Professional | | $794.33 | $794.33 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $954.99 / $4,265.80
| Professional | | $616.60 | $954.99 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,089.30 / $3,715.35
| Professional | | $1,905.46 | $2,089.30 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,548.82
| Professional | | $1,318.26 | $1,318.26 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,888.44 / $10,471.29
| Facility | | $1,698.24 | $5,888.44 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $977.24 / $2,137.96
| Professional | | $676.08 | $977.24 | $2,137.96 |