- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,897.79 / $10,471.29
| Facility | | $2,754.23 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,659.59 / $4,265.80
| Professional | | $1,258.93 | $1,659.59 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $17,378.01 / $31,622.78
| Facility | | $8,912.51 | $17,378.01 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,818.38 / $3,548.13
| Professional | | $1,380.38 | $2,818.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,398.83 / $3,981.07
| Professional | | $1,659.59 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,818.38
| Professional | | $2,398.83 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,165.95 / $15,135.61
| Facility | | $3,311.31 | $6,165.95 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,995.26 / $3,715.35
| Professional | | $1,380.38 | $1,995.26 | $3,715.35 |