- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,897.79 / $10,471.29
| Facility | | $2,511.89 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $3,890.45
| Professional | | $1,148.15 | $1,513.56 | $3,890.45 |
- 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
- $1,288.25 / $2,570.40 / $3,235.94
| Professional | | $1,288.25 | $2,570.40 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $3,630.78
| Professional | | $1,479.11 | $2,187.76 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,511.89
| Professional | | $2,187.76 | $2,187.76 | $2,511.89 |
- 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
- $1,258.93 / $1,819.70 / $3,388.44
| Professional | | $1,258.93 | $1,819.70 | $3,388.44 |