- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,897.79 / $10,471.29
| Facility | | $2,630.27 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,584.89 / $3,981.07
| Professional | | $1,202.26 | $1,584.89 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,848.93 / $16,595.87
| Facility | | $8,317.64 | $15,848.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,630.27 / $3,388.44
| Professional | | $1,348.96 | $2,630.27 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,398.83 / $3,548.13
| Professional | | $1,584.89 | $2,398.83 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,630.27
| Professional | | $2,187.76 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,165.95 / $15,135.61
| Facility | | $3,311.31 | $6,165.95 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $3,548.13
| Professional | | $1,318.26 | $1,905.46 | $3,548.13 |