- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,897.79 / $10,471.29
| Facility | | $2,570.40 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $3,715.35
| Professional | | $1,202.26 | $1,548.82 | $3,715.35 |
- 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
- $1,348.96 / $2,570.40 / $3,388.44
| Professional | | $1,348.96 | $2,570.40 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,238.72 / $3,715.35
| Professional | | $1,584.89 | $2,238.72 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,754.23
| Professional | | $2,344.23 | $2,344.23 | $2,754.23 |
- 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
- $1,288.25 / $1,905.46 / $3,981.07
| Professional | | $1,288.25 | $1,905.46 | $3,981.07 |