- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,897.79 / $10,471.29
| Facility | | $2,570.40 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,737.80 / $3,981.07
| Professional | | $1,348.96 | $1,737.80 | $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
- $1,348.96 / $3,090.30 / $3,548.13
| Professional | | $1,348.96 | $3,090.30 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,290.87 / $3,715.35
| Professional | | $1,548.82 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,630.27
| Professional | | $2,290.87 | $2,290.87 | $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
- $1,445.44 / $2,187.76 / $4,365.16
| Professional | | $1,445.44 | $2,187.76 | $4,365.16 |