- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,897.79 / $10,471.29
| Facility | | $3,801.89 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $5,754.40
| Professional | | $1,698.24 | $2,290.87 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,848.93 / $16,595.87
| Facility | | $8,317.64 | $15,848.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,890.45 / $5,011.87
| Professional | | $1,949.84 | $3,890.45 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,311.31 / $5,128.61
| Professional | | $2,238.72 | $3,311.31 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,467.37
| Professional | | $3,311.31 | $3,311.31 | $3,467.37 |
- 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
- $1,778.28 / $2,691.53 / $5,011.87
| Professional | | $1,778.28 | $2,691.53 | $5,011.87 |