- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,165.95 / $11,481.54
| Facility | | $3,235.94 | $6,165.95 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,949.84 / $3,162.28
| Professional | | $1,412.54 | $1,949.84 | $3,162.28 |
- 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
- $1,513.56 / $2,884.03 / $3,548.13
| Professional | | $1,513.56 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $3,981.07
| Professional | | $1,995.26 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,019.95
| Professional | | $2,398.83 | $2,398.83 | $3,019.95 |
- 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
- $1,584.89 / $2,290.87 / $4,168.69
| Professional | | $1,584.89 | $2,290.87 | $4,168.69 |