- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $8,511.38 / $14,791.08
| Facility | | $2,691.53 | $8,511.38 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $2,951.21
| Professional | | $1,258.93 | $1,548.82 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $16,595.87 / $18,620.87
| Facility | | $8,709.64 | $16,595.87 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,691.53 / $3,467.37
| Professional | | $1,348.96 | $2,691.53 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,238.72 / $3,467.37
| Professional | | $1,621.81 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,630.27
| Professional | | $2,344.23 | $2,344.23 | $2,630.27 |
- 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
- $1,445.44 / $1,949.84 / $3,890.45
| Professional | | $1,445.44 | $1,949.84 | $3,890.45 |