- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,897.79 / $10,471.29
| Facility | | $2,398.83 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $4,073.80
| Professional | | $1,258.93 | $1,621.81 | $4,073.80 |
- 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
- $1,288.25 / $3,019.95 / $3,630.78
| Professional | | $1,288.25 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $3,548.13
| Professional | | $1,479.11 | $2,238.72 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,398.83
| Professional | | $2,238.72 | $2,238.72 | $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 |