- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,248.07 / $9,549.93
| Facility | | $2,570.40 | $5,248.07 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $3,548.13
| Professional | | $1,023.29 | $1,412.54 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $13,803.84 / $19,952.62
| Facility | | $4,786.30 | $13,803.84 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,238.72 / $2,951.21
| Professional | | $1,148.15 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,137.96 / $3,090.30
| Professional | | $1,412.54 | $2,137.96 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,089.30
| Professional | | $1,995.26 | $1,995.26 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,709.64 / $11,748.98
| Facility | | $5,754.40 | $8,709.64 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $3,090.30
| Professional | | $1,148.15 | $1,659.59 | $3,090.30 |