- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,897.79 / $10,471.29
| Facility | | $3,019.95 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $4,365.16
| Professional | | $1,445.44 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,848.93 / $16,595.87
| Facility | | $8,317.64 | $15,848.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,162.28 / $3,981.07
| Professional | | $1,584.89 | $3,162.28 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,691.53 / $5,011.87
| Professional | | $1,862.09 | $2,691.53 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,090.30
| Professional | | $3,019.95 | $3,019.95 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,165.95 / $15,135.61
| Facility | | $3,311.31 | $6,165.95 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $4,265.80
| Professional | | $1,548.82 | $2,041.74 | $4,265.80 |