- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,897.79 / $10,471.29
| Facility | | $3,467.37 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $5,888.44
| Professional | | $1,819.70 | $2,398.83 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,135.61 / $16,595.87
| Facility | | $8,317.64 | $15,135.61 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,265.80 / $5,128.61
| Professional | | $1,819.70 | $4,265.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,235.94 / $5,011.87
| Professional | | $2,137.96 | $3,235.94 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,467.37
| Professional | | $3,235.94 | $3,235.94 | $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
- $1,995.26 / $2,951.21 / $6,025.60
| Professional | | $1,995.26 | $2,951.21 | $6,025.60 |