- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,495.41 / $10,964.78
| Facility | | $3,090.30 | $5,495.41 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $4,365.16
| Professional | | $1,659.59 | $2,137.96 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $12,022.64 / $22,387.21
| Facility | | $5,623.41 | $12,022.64 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,090.30 / $4,897.79
| Professional | | $2,344.23 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,073.80 / $10,232.93
| Professional | | $3,388.44 | $4,073.80 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,454.71
| Professional | | $1,737.80 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $13,803.84 / $20,417.38
| Facility | | $10,471.29 | $13,803.84 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,884.03 / $5,248.07
| Professional | | $1,445.44 | $2,884.03 | $5,248.07 |