- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,897.79 / $8,511.38
| Facility | | $2,691.53 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,318.26 / $2,691.53
| Professional | | $1,071.52 | $1,318.26 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $13,803.84 / $16,595.87
| Facility | | $6,606.93 | $13,803.84 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,187.76 / $2,818.38
| Professional | | $1,096.48 | $2,187.76 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,862.09 / $3,019.95
| Professional | | $1,348.96 | $1,862.09 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,041.74
| Professional | | $1,862.09 | $1,862.09 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,709.64 / $11,748.98
| Facility | | $5,754.40 | $8,709.64 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $3,388.44
| Professional | | $1,071.52 | $1,513.56 | $3,388.44 |