- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,897.79 / $10,471.29
| Facility | | $3,548.13 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $4,365.16
| Professional | | $1,778.28 | $2,187.76 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,135.61 / $16,595.87
| Facility | | $8,317.64 | $15,135.61 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,548.13 / $4,677.35
| Professional | | $1,819.70 | $3,548.13 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,090.30 / $4,897.79
| Professional | | $2,187.76 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,311.31
| Professional | | $3,090.30 | $3,090.30 | $3,311.31 |
- 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 / $2,511.89 / $5,495.41
| Professional | | $1,778.28 | $2,511.89 | $5,495.41 |