- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,623.41 / $7,413.10
| Facility | | $3,801.89 | $5,623.41 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,168.69 / $5,623.41
| Professional | | $1,202.26 | $4,168.69 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,760.83 / $14,454.40
| Facility | | $2,290.87 | $6,760.83 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $2,691.53
| Professional | | $1,621.81 | $1,949.84 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,488.17 / $16,595.87 / $16,595.87
| Facility | | $15,488.17 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,677.35 / $6,760.83
| Professional | | $3,548.13 | $4,677.35 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $9,120.11 / $19,498.45
| Facility | | $2,290.87 | $9,120.11 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $8,709.64
| Professional | | $977.24 | $1,479.11 | $8,709.64 |