- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,897.79 / $10,471.29
| Facility | | $3,388.44 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,290.87 / $5,495.41
| Professional | | $1,778.28 | $2,290.87 | $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
- $1,778.28 / $3,981.07 / $4,570.88
| Professional | | $1,778.28 | $3,981.07 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $4,897.79
| Professional | | $2,089.30 | $3,019.95 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,467.37
| Professional | | $3,090.30 | $3,090.30 | $3,467.37 |
- 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
- $1,905.46 / $3,019.95 / $5,754.40
| Professional | | $1,905.46 | $3,019.95 | $5,754.40 |