- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,495.41 / $10,715.19
| Facility | | $3,311.31 | $5,495.41 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $512.86 / $1,584.89
| Professional | | $436.52 | $512.86 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $691.83 / $1,584.89
| Professional | | $436.52 | $691.83 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $588.84 / $776.25
| Professional | | $436.52 | $588.84 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $16,218.10 / $25,703.96
| Facility | | $10,964.78 | $16,218.10 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $524.81 / $1,122.02
| Professional | | $380.19 | $524.81 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,248.07 / $9,332.54
| Facility | | $2,570.40 | $5,248.07 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $467.74 / $1,023.29
| Professional | | $302.00 | $467.74 | $1,023.29 |