- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,897.79 / $10,471.29
| Facility | | $3,235.94 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $5,011.87
| Professional | | $1,621.81 | $2,137.96 | $5,011.87 |
- 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
- $1,659.59 / $3,715.35 / $4,265.80
| Professional | | $1,659.59 | $3,715.35 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,818.38 / $4,677.35
| Professional | | $1,905.46 | $2,818.38 | $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 / $2,691.53 / $5,370.32
| Professional | | $1,778.28 | $2,691.53 | $5,370.32 |