- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,754.40 / $14,125.38
| Facility | | $1,513.56 | $5,754.40 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,258.93 / $3,235.94
| Professional | | $1,047.13 | $1,258.93 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $9,120.11 / $17,782.79
| Facility | | $3,548.13 | $9,120.11 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,584.89 / $2,818.38
| Professional | | $1,071.52 | $1,584.89 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,715.35 / $10,232.93
| Facility | | $1,995.26 | $3,715.35 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,659.59 / $3,630.78
| Professional | | $1,047.13 | $1,659.59 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,244.36 / $16,218.10
| Facility | | $2,454.71 | $7,244.36 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,348.96 / $2,570.40
| Professional | | $954.99 | $1,348.96 | $2,570.40 |