- 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
- $1,621.81 / $2,041.74 / $5,248.07
| Professional | | $1,621.81 | $2,041.74 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $14,125.38 / $16,595.87
| Facility | | $8,317.64 | $14,125.38 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,715.35 / $4,265.80
| Professional | | $1,621.81 | $3,715.35 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $4,466.84
| Professional | | $1,949.84 | $2,884.03 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,019.95
| Professional | | $2,884.03 | $2,884.03 | $3,019.95 |
- 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
- $1,819.70 / $2,691.53 / $5,623.41
| Professional | | $1,819.70 | $2,691.53 | $5,623.41 |