- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,677.35 / $10,471.29
| Facility | | $2,290.87 | $4,677.35 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,380.38 / $3,467.37
| Professional | | $1,071.52 | $1,380.38 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $16,218.10 / $18,620.87
| Facility | | $7,413.10 | $16,218.10 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,290.87 / $2,884.03
| Professional | | $1,174.90 | $2,290.87 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,949.84 / $3,311.31
| Professional | | $1,348.96 | $1,949.84 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,344.23
| Professional | | $1,949.84 | $1,949.84 | $2,344.23 |
- 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
- $1,148.15 / $1,621.81 / $3,090.30
| Professional | | $1,148.15 | $1,621.81 | $3,090.30 |