- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,897.79 / $10,471.29
| Facility | | $3,630.78 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,041.74 / $5,011.87
| Professional | | $1,737.80 | $2,041.74 | $5,011.87 |
- 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
- $1,819.70 / $3,630.78 / $4,786.30
| Professional | | $1,819.70 | $3,630.78 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,162.28 / $4,897.79
| Professional | | $2,187.76 | $3,162.28 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,388.44
| Professional | | $3,235.94 | $3,235.94 | $3,388.44 |
- 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
- $1,659.59 / $2,570.40 / $5,248.07
| Professional | | $1,659.59 | $2,570.40 | $5,248.07 |