- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $12,882.50 / $20,417.38
| Facility | | $3,715.35 | $12,882.50 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,884.03 / $3,548.13
| Professional | | $2,041.74 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $10,715.19 / $17,782.79
| Facility | | $4,677.35 | $10,715.19 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $3,715.35
| Professional | | $1,548.82 | $1,548.82 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $11,220.18
| Facility | | $1,949.84 | $2,398.83 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $5,370.32
| Professional | | $4,466.84 | $4,466.84 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,248.07
| Professional | | $5,128.61 | $5,128.61 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $3,715.35
| Professional | | $2,570.40 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,187.76
| Professional | | $1,548.82 | $1,548.82 | $2,187.76 |