- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,897.79 / $10,471.29
| Facility | | $3,388.44 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $4,168.69
| Professional | | $1,698.24 | $2,041.74 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,302.69 / $13,803.84
| Facility | | $7,413.10 | $12,302.69 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,388.44 / $4,365.16
| Professional | | $1,737.80 | $3,388.44 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,884.03 / $4,677.35
| Professional | | $2,041.74 | $2,884.03 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,162.28
| Professional | | $2,884.03 | $2,884.03 | $3,162.28 |
- 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
- $1,698.24 / $2,398.83 / $5,248.07
| Professional | | $1,698.24 | $2,398.83 | $5,248.07 |