- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,165.95 / $15,848.93
| Facility | | $2,951.21 | $6,165.95 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,884.03 / $3,981.07
| Professional | | $2,290.87 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,466.84 / $15,848.93
| Facility | | $3,235.94 | $4,466.84 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $323.59 / $5,623.41
| Professional | | $239.88 | $323.59 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,760.83 / $14,791.08
| Facility | | $2,290.87 | $6,760.83 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,128.61 / $9,549.93
| Professional | | $3,981.07 | $5,128.61 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,467.37 / $4,168.69
| Facility | | $2,089.30 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $4,168.69
| Professional | | $1,479.11 | $2,089.30 | $4,168.69 |