- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,025.60 / $10,964.78
| Facility | | $4,570.88 | $6,025.60 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,951.21 / $7,079.46
| Professional | | $2,137.96 | $2,951.21 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $17,378.01 / $26,915.35
| Facility | | $8,912.51 | $17,378.01 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,897.79 / $6,309.57
| Professional | | $2,570.40 | $4,897.79 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $9,549.93
| Facility | | $1,047.13 | $1,047.13 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,677.35 / $7,413.10
| Professional | | $3,235.94 | $4,677.35 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,981.07 / $5,248.07
| Professional | | $2,570.40 | $3,981.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $10,964.78 / $18,620.87
| Facility | | $7,244.36 | $10,964.78 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,168.69 / $7,762.47
| Professional | | $2,454.71 | $4,168.69 | $7,762.47 |