- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,897.79 / $10,471.29
| Facility | | $2,089.30 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $3,630.78
| Professional | | $1,096.48 | $1,380.38 | $3,630.78 |
- 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
- $1,096.48 / $2,511.89 / $2,884.03
| Professional | | $1,096.48 | $2,511.89 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,949.84 / $3,090.30
| Professional | | $1,288.25 | $1,949.84 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,089.30
| Professional | | $1,995.26 | $1,995.26 | $2,089.30 |
- 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
- $1,202.26 / $1,778.28 / $3,630.78
| Professional | | $1,202.26 | $1,778.28 | $3,630.78 |