- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,897.79 / $10,471.29
| Facility | | $2,290.87 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $3,467.37
| Professional | | $1,202.26 | $1,548.82 | $3,467.37 |
- 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
- $1,202.26 / $2,754.23 / $3,090.30
| Professional | | $1,202.26 | $2,754.23 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,995.26 / $3,388.44
| Professional | | $1,380.38 | $1,995.26 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,398.83
| Professional | | $2,089.30 | $2,089.30 | $2,398.83 |
- 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
- $1,288.25 / $1,995.26 / $3,890.45
| Professional | | $1,288.25 | $1,995.26 | $3,890.45 |