- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,897.79 / $10,471.29
| Facility | | $3,090.30 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $4,786.30
| Professional | | $1,445.44 | $1,862.09 | $4,786.30 |
- 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
- $1,584.89 / $3,162.28 / $3,981.07
| Professional | | $1,584.89 | $3,162.28 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,691.53 / $4,466.84
| Professional | | $1,819.70 | $2,691.53 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,090.30
| Professional | | $2,691.53 | $2,691.53 | $3,090.30 |
- 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
- $1,548.82 / $2,238.72 / $4,168.69
| Professional | | $1,548.82 | $2,238.72 | $4,168.69 |