- 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
- $1,621.81 / $2,041.74 / $4,897.79
| Professional | | $1,621.81 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $17,378.01 / $36,307.81
| Facility | | $9,120.11 | $17,378.01 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,630.78 / $4,168.69
| Professional | | $1,621.81 | $3,630.78 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $4,466.84
| Professional | | $1,862.09 | $2,630.27 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,162.28
| Professional | | $2,754.23 | $2,754.23 | $3,162.28 |
- 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
- $1,737.80 / $2,570.40 / $5,248.07
| Professional | | $1,737.80 | $2,570.40 | $5,248.07 |