- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,290.87 / $4,073.80
| Facility | | $758.58 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,174.90 / $2,454.71
| Professional | | $977.24 | $1,174.90 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $4,073.80 / $5,888.44
| Facility | | $1,949.84 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,659.59 / $2,570.40
| Professional | | $1,202.26 | $1,659.59 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $2,398.83
| Professional | | $1,047.13 | $1,412.54 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $18,620.87 / $28,840.32
| Facility | | $18,620.87 | $18,620.87 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $9,549.93 / $9,549.93
| Professional | | $8,128.31 | $9,549.93 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $10,232.93
| Facility | | $3,235.94 | $5,754.40 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,187.76
| Professional | | $933.25 | $1,318.26 | $2,187.76 |