- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $14,125.38
| Facility | | $4,365.16 | $7,079.46 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $3,548.13
| Professional | | $1,174.90 | $1,445.44 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,168.69 / $12,022.64
| Facility | | $3,715.35 | $4,168.69 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,398.83 / $3,090.30
| Professional | | $1,230.27 | $2,398.83 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,041.74 / $3,235.94
| Professional | | $1,412.54 | $2,041.74 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,238.72
| Professional | | $2,041.74 | $2,041.74 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,079.46 / $11,220.18
| Facility | | $4,570.88 | $7,079.46 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,698.24 / $3,235.94
| Professional | | $1,174.90 | $1,698.24 | $3,235.94 |