- 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
- $1,584.89 / $1,905.46 / $3,801.89
| Professional | | $1,584.89 | $1,905.46 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $11,481.54 / $23,988.33
| Facility | | $6,025.60 | $11,481.54 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,238.72 / $3,090.30
| Professional | | $1,778.28 | $2,238.72 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,398.83 / $3,235.94
| Professional | | $1,862.09 | $2,398.83 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,041.74 / $6,918.31
| Professional | | $1,995.26 | $2,041.74 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,621.81
| Professional | | $1,445.44 | $1,445.44 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $6,760.83 / $12,882.50
| Facility | | $2,630.27 | $6,760.83 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $3,981.07
| Professional | | $1,862.09 | $2,454.71 | $3,981.07 |