- 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
- $1,412.54 / $1,819.70 / $4,073.80
| Professional | | $1,412.54 | $1,819.70 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,135.61 / $16,595.87
| Facility | | $8,317.64 | $15,135.61 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,019.95 / $3,890.45
| Professional | | $1,584.89 | $3,019.95 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $4,365.16
| Professional | | $1,862.09 | $2,630.27 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,235.94
| Professional | | $2,754.23 | $2,754.23 | $3,235.94 |
- 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
- $1,513.56 / $2,187.76 / $4,677.35
| Professional | | $1,513.56 | $2,187.76 | $4,677.35 |