- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,897.79 / $10,471.29
| Facility | | $3,548.13 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $5,623.41
| Professional | | $1,659.59 | $2,238.72 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $17,378.01 / $19,952.62
| Facility | | $8,709.64 | $17,378.01 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,168.69 / $4,786.30
| Professional | | $1,819.70 | $4,168.69 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,235.94 / $5,128.61
| Professional | | $2,137.96 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,548.13
| Professional | | $2,691.53 | $2,691.53 | $3,548.13 |
- 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
- $1,995.26 / $3,019.95 / $6,025.60
| Professional | | $1,995.26 | $3,019.95 | $6,025.60 |