- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,897.79 / $10,471.29
| Facility | | $2,454.71 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $4,168.69
| Professional | | $1,258.93 | $1,737.80 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,135.61 / $16,595.87
| Facility | | $8,317.64 | $15,135.61 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,884.03 / $3,311.31
| Professional | | $1,288.25 | $2,884.03 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,290.87 / $3,548.13
| Professional | | $1,479.11 | $2,290.87 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $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
- $1,380.38 / $2,041.74 / $4,168.69
| Professional | | $1,380.38 | $2,041.74 | $4,168.69 |