- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,365.16 / $5,495.41
| Facility | | $3,388.44 | $4,365.16 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $4,365.16
| Professional | | $1,819.70 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $8,317.64 / $15,848.93
| Facility | | $1,621.81 | $8,317.64 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Professional | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,570.40 / $5,495.41
| Facility | | $1,819.70 | $2,570.40 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $4,365.16
| Professional | | $1,621.81 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $16,218.10
| Facility | | $8,511.38 | $11,748.98 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $12,302.69 / $13,489.63
| Professional | | $8,317.64 | $12,302.69 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $12,302.69 / $12,302.69
| Facility | | $5,495.41 | $12,302.69 | $12,302.69 |