- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,495.41 / $10,715.19
| Facility | | $2,754.23 | $5,495.41 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,570.40 / $3,715.35
| Professional | | $2,290.87 | $2,570.40 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,549.93 / $17,378.01
| Facility | | $4,570.88 | $9,549.93 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $5,248.07
| Professional | | $2,630.27 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $4,168.69
| Professional | | $2,290.87 | $3,235.94 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,589.25 / $12,589.25 / $12,589.25
| Professional | | $12,589.25 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $1,949.84
| Professional | | $1,584.89 | $1,905.46 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $8,128.31 / $16,595.87
| Facility | | $3,548.13 | $8,128.31 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $5,888.44
| Professional | | $2,691.53 | $3,467.37 | $5,888.44 |