- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,897.79 / $10,471.29
| Facility | | $2,691.53 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,819.70 / $3,981.07
| Professional | | $1,412.54 | $1,819.70 | $3,981.07 |
- 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
- $1,412.54 / $3,162.28 / $3,630.78
| Professional | | $1,412.54 | $3,162.28 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,454.71 / $3,981.07
| Professional | | $1,621.81 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,754.23
| Professional | | $2,398.83 | $2,398.83 | $2,754.23 |
- 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
- $1,513.56 / $2,398.83 / $4,570.88
| Professional | | $1,513.56 | $2,398.83 | $4,570.88 |