- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,370.32 / $10,715.19
| Facility | | $3,090.30 | $5,370.32 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,621.81 / $3,090.30
| Professional | | $1,412.54 | $1,621.81 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $15,135.61 / $28,183.83
| Facility | | $7,762.47 | $15,135.61 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $2,884.03
| Professional | | $1,548.82 | $2,041.74 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $2,137.96
| Facility | | $794.33 | $794.33 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $3,090.30
| Professional | | $1,548.82 | $2,187.76 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,041.74 / $6,309.57
| Professional | | $1,445.44 | $2,041.74 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,513.56
| Professional | | $1,445.44 | $1,445.44 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,754.40 / $9,549.93
| Facility | | $2,238.72 | $5,754.40 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $3,467.37
| Professional | | $1,621.81 | $2,344.23 | $3,467.37 |