- 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
- $1,380.38 / $1,698.24 / $3,467.37
| Professional | | $1,380.38 | $1,698.24 | $3,467.37 |
- 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 / $2,630.27 / $3,311.31
| Professional | | $1,621.81 | $2,630.27 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $4,466.84
| Professional | | $1,778.28 | $2,398.83 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $3,388.44
| Professional | | $2,089.30 | $2,089.30 | $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
- $1,479.11 / $2,238.72 / $4,786.30
| Professional | | $1,479.11 | $2,238.72 | $4,786.30 |