- 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
- $1,698.24 / $2,187.76 / $5,128.61
| Professional | | $1,698.24 | $2,187.76 | $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
- $1,698.24 / $3,801.89 / $4,365.16
| Professional | | $1,698.24 | $3,801.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $4,786.30
| Professional | | $1,949.84 | $2,884.03 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,311.31
| Professional | | $3,090.30 | $3,090.30 | $3,311.31 |
- 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
- $1,819.70 / $2,754.23 / $5,495.41
| Professional | | $1,819.70 | $2,754.23 | $5,495.41 |