- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,165.95 / $11,481.54
| Facility | | $2,818.38 | $6,165.95 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,818.38
| Professional | | $1,288.25 | $1,698.24 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $13,182.57 / $16,595.87
| Facility | | $4,786.30 | $13,182.57 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,570.40 / $3,162.28
| Professional | | $1,348.96 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,511.89 / $3,715.35
| Professional | | $1,737.80 | $2,511.89 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,630.27
| Professional | | $2,238.72 | $2,238.72 | $2,630.27 |
- 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
- $1,380.38 / $2,041.74 / $3,715.35
| Professional | | $1,380.38 | $2,041.74 | $3,715.35 |