- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,128.61 / $13,489.63
| Facility | | $2,630.27 | $5,128.61 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $2,818.38
| Professional | | $1,905.46 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,570.88 / $14,125.38
| Facility | | $2,454.71 | $4,570.88 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,174.90 / $3,388.44
| Professional | | $851.14 | $1,174.90 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,623.41 / $12,302.69
| Facility | | $1,905.46 | $5,623.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,265.80 / $7,943.28
| Professional | | $3,388.44 | $4,265.80 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,884.03 / $3,467.37
| Facility | | $1,737.80 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $3,467.37
| Professional | | $1,230.27 | $1,737.80 | $3,467.37 |