- 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
- $1,737.80 / $2,454.71 / $5,495.41
| Professional | | $1,737.80 | $2,454.71 | $5,495.41 |
- 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
- $2,290.87 / $2,884.03 / $5,623.41
| Professional | | $2,290.87 | $2,884.03 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,801.89
| Professional | | $2,884.03 | $2,884.03 | $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
- $2,089.30 / $2,951.21 / $6,456.54
| Professional | | $2,089.30 | $2,951.21 | $6,456.54 |