- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,897.79 / $10,471.29
| Facility | | $2,511.89 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $4,073.80
| Professional | | $1,288.25 | $1,659.59 | $4,073.80 |
- 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
- $1,288.25 / $2,951.21 / $3,311.31
| Professional | | $1,288.25 | $2,951.21 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $3,548.13
| Professional | | $1,513.56 | $2,238.72 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,570.40
| Professional | | $2,238.72 | $2,238.72 | $2,570.40 |
- 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
- $1,380.38 / $2,187.76 / $4,168.69
| Professional | | $1,380.38 | $2,187.76 | $4,168.69 |