- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,897.79 / $10,471.29
| Facility | | $3,162.28 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $5,128.61
| Professional | | $1,659.59 | $2,137.96 | $5,128.61 |
- 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
- $1,380.38 / $3,801.89 / $4,365.16
| Professional | | $1,380.38 | $3,801.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,884.03 / $4,677.35
| Professional | | $1,905.46 | $2,884.03 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,235.94
| Professional | | $2,818.38 | $2,818.38 | $3,235.94 |
- 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
- $1,778.28 / $2,630.27 / $5,495.41
| Professional | | $1,778.28 | $2,630.27 | $5,495.41 |