- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,897.79 / $10,471.29
| Facility | | $3,630.78 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $4,073.80
| Professional | | $1,698.24 | $2,238.72 | $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
- $1,995.26 / $4,265.80 / $4,786.30
| Professional | | $1,995.26 | $4,265.80 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $6,165.95
| Professional | | $2,187.76 | $3,388.44 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- 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
- $2,041.74 / $3,467.37 / $6,165.95
| Professional | | $2,041.74 | $3,467.37 | $6,165.95 |