- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,897.79 / $10,471.29
| Facility | | $2,884.03 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $4,570.88
| Professional | | $1,513.56 | $1,905.46 | $4,570.88 |
- 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
- $1,513.56 / $3,388.44 / $3,890.45
| Professional | | $1,513.56 | $3,388.44 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $4,265.80
| Professional | | $1,737.80 | $2,454.71 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,951.21
| Professional | | $2,570.40 | $2,570.40 | $2,951.21 |
- 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
- $1,621.81 / $2,398.83 / $4,897.79
| Professional | | $1,621.81 | $2,398.83 | $4,897.79 |