- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,897.79 / $10,471.29
| Facility | | $3,311.31 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $5,128.61
| Professional | | $1,659.59 | $2,238.72 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $11,748.98 / $13,803.84
| Facility | | $2,754.23 | $11,748.98 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,801.89 / $4,365.16
| Professional | | $1,737.80 | $3,801.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $4,897.79
| Professional | | $1,949.84 | $2,818.38 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,388.44
| Professional | | $2,818.38 | $2,818.38 | $3,388.44 |
- 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 / $2,754.23 / $5,623.41
| Professional | | $1,778.28 | $2,754.23 | $5,623.41 |