- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,897.79 / $10,471.29
| Facility | | $3,801.89 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,511.89 / $5,754.40
| Professional | | $1,949.84 | $2,511.89 | $5,754.40 |
- 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
- $1,995.26 / $4,466.84 / $5,128.61
| Professional | | $1,995.26 | $4,466.84 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,818.38 / $5,495.41
| Professional | | $2,137.96 | $2,818.38 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,801.89
| Professional | | $3,388.44 | $3,388.44 | $3,801.89 |
- 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
- $1,995.26 / $2,951.21 / $6,456.54
| Professional | | $1,995.26 | $2,951.21 | $6,456.54 |