- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,897.79 / $10,471.29
| Facility | | $2,398.83 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $3,801.89
| Professional | | $1,174.90 | $1,513.56 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $17,378.01 / $19,952.62
| Facility | | $8,709.64 | $17,378.01 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $3,235.94
| Professional | | $1,230.27 | $2,951.21 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,137.96 / $3,467.37
| Professional | | $1,445.44 | $2,137.96 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,398.83
| Professional | | $1,949.84 | $1,949.84 | $2,398.83 |
- 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
- $1,348.96 / $2,041.74 / $4,073.80
| Professional | | $1,348.96 | $2,041.74 | $4,073.80 |