- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,897.79 / $10,471.29
| Facility | | $3,162.28 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,778.28 / $4,570.88
| Professional | | $1,445.44 | $1,778.28 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $21,877.62 / $26,915.35
| Facility | | $8,912.51 | $21,877.62 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,162.28 / $4,073.80
| Professional | | $1,621.81 | $3,162.28 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,754.23 / $4,570.88
| Professional | | $1,949.84 | $2,754.23 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,388.44
| Professional | | $2,884.03 | $2,884.03 | $3,388.44 |
- 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
- $1,584.89 / $2,344.23 / $4,897.79
| Professional | | $1,584.89 | $2,344.23 | $4,897.79 |