- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,511.38 / $14,125.38
| Facility | | $4,570.88 | $8,511.38 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $2,951.21
| Professional | | $1,148.15 | $1,445.44 | $2,951.21 |
- 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
- $1,230.27 / $2,454.71 / $3,235.94
| Professional | | $1,230.27 | $2,454.71 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,290.87 / $3,162.28
| Professional | | $1,513.56 | $2,290.87 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,398.83
| Professional | | $2,290.87 | $2,290.87 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,471.29 / $16,218.10
| Facility | | $6,456.54 | $10,471.29 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $3,467.37
| Professional | | $1,380.38 | $1,862.09 | $3,467.37 |