- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $10,964.78
| Facility | | $4,466.84 | $6,918.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $691.83 / $2,089.30
| Professional | | $588.84 | $691.83 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $891.25 / $2,187.76
| Professional | | $478.63 | $891.25 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $1,096.48
| Professional | | $602.56 | $812.83 | $1,096.48 |
- 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
- $512.86 / $758.58 / $1,548.82
| Professional | | $512.86 | $758.58 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,606.93 / $10,964.78
| Facility | | $2,951.21 | $6,606.93 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $630.96 / $1,380.38
| Professional | | $426.58 | $630.96 | $1,380.38 |