- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,079.46 / $19,952.62
| Facility | | $3,388.44 | $7,079.46 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,621.81 / $4,786.30
| Professional | | $1,412.54 | $1,621.81 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $16,982.44 / $19,952.62
| Facility | | $8,709.64 | $16,982.44 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,511.89 / $3,311.31
| Professional | | $1,412.54 | $2,511.89 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,884.03 / $5,248.07
| Professional | | $2,041.74 | $2,884.03 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,090.30
| Professional | | $2,238.72 | $2,238.72 | $3,090.30 |
- 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
- $1,584.89 / $2,187.76 / $3,890.45
| Professional | | $1,584.89 | $2,187.76 | $3,890.45 |