- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $6,025.60 / $10,964.78
| Facility | | $3,090.30 | $6,025.60 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,862.09 / $3,715.35
| Professional | | $1,621.81 | $1,862.09 | $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
- $1,995.26 / $2,570.40 / $4,073.80
| Professional | | $1,995.26 | $2,570.40 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,398.83 / $3,981.07
| Professional | | $1,862.09 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,511.89 / $4,365.16
| Professional | | $1,778.28 | $2,511.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,818.38
| Professional | | $1,778.28 | $1,778.28 | $2,818.38 |
- 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
- $1,862.09 / $2,398.83 / $4,466.84
| Professional | | $1,862.09 | $2,398.83 | $4,466.84 |