- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,317.64 / $16,218.10
| Facility | | $4,570.88 | $8,317.64 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $2,951.21
| Professional | | $1,122.02 | $1,348.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,135.61 / $16,595.87
| Facility | | $8,317.64 | $15,135.61 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,344.23 / $3,019.95
| Professional | | $1,122.02 | $2,344.23 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,041.74 / $3,090.30
| Professional | | $1,348.96 | $2,041.74 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,238.72
| Professional | | $2,137.96 | $2,137.96 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,471.29 / $16,218.10
| Facility | | $6,456.54 | $10,471.29 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,584.89 / $3,388.44
| Professional | | $1,071.52 | $1,584.89 | $3,388.44 |