- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,897.79 / $10,471.29
| Facility | | $3,981.07 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,511.89 / $4,073.80
| Professional | | $1,412.54 | $2,511.89 | $4,073.80 |
- 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
- $2,041.74 / $4,365.16 / $5,011.87
| Professional | | $2,041.74 | $4,365.16 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,630.27 / $6,165.95
| Professional | | $1,905.46 | $2,630.27 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,890.45
| Professional | | $2,398.83 | $2,398.83 | $3,890.45 |
- 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
- $1,949.84 / $2,884.03 / $6,760.83
| Professional | | $1,949.84 | $2,884.03 | $6,760.83 |