- 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
- $1,380.38 / $1,737.80 / $4,466.84
| Professional | | $1,380.38 | $1,737.80 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $14,125.38 / $16,595.87
| Facility | | $8,317.64 | $14,125.38 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,162.28 / $3,630.78
| Professional | | $1,380.38 | $3,162.28 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,454.71 / $3,801.89
| Professional | | $1,621.81 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,630.27
| Professional | | $2,454.71 | $2,454.71 | $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
- $1,479.11 / $2,238.72 / $4,570.88
| Professional | | $1,479.11 | $2,238.72 | $4,570.88 |