- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $8,511.38 / $13,489.63
| Facility | | $3,801.89 | $8,511.38 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $2,951.21
| Professional | | $1,819.70 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $295.12 / $4,786.30
| Professional | | $239.88 | $295.12 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,456.54 / $27,542.29
| Facility | | $4,897.79 | $6,456.54 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,466.84 / $14,791.08
| Professional | | $3,548.13 | $4,466.84 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,089.30 / $3,019.95
| Facility | | $1,288.25 | $2,089.30 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $3,981.07
| Professional | | $1,288.25 | $1,819.70 | $3,981.07 |