- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,370.32 / $10,715.19
| Facility | | $3,162.28 | $5,370.32 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,801.89 / $7,079.46
| Professional | | $3,162.28 | $3,801.89 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,549.93 / $17,378.01
| Facility | | $4,570.88 | $9,549.93 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,677.35 / $6,760.83
| Professional | | $3,630.78 | $4,677.35 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $7,413.10
| Professional | | $5,888.44 | $5,888.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,677.35 / $15,488.17
| Professional | | $3,311.31 | $4,677.35 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,548.13
| Professional | | $3,311.31 | $3,311.31 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,754.40 / $9,549.93
| Facility | | $2,238.72 | $5,754.40 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,897.79 / $7,762.47
| Professional | | $3,467.37 | $4,897.79 | $7,762.47 |