- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,897.79 / $10,471.29
| Facility | | $3,090.30 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,041.74 / $4,786.30
| Professional | | $1,584.89 | $2,041.74 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $17,378.01 / $19,952.62
| Facility | | $8,709.64 | $17,378.01 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,630.78 / $4,168.69
| Professional | | $1,584.89 | $3,630.78 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,754.23 / $4,265.80
| Professional | | $1,819.70 | $2,754.23 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,162.28
| Professional | | $2,691.53 | $2,691.53 | $3,162.28 |
- 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
- $1,737.80 / $2,630.27 / $5,248.07
| Professional | | $1,737.80 | $2,630.27 | $5,248.07 |