- 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
- $1,659.59 / $2,089.30 / $4,897.79
| Professional | | $1,659.59 | $2,089.30 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $21,877.62 / $26,915.35
| Facility | | $8,912.51 | $21,877.62 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,548.13 / $4,570.88
| Professional | | $1,819.70 | $3,548.13 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $5,011.87
| Professional | | $2,137.96 | $3,019.95 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,715.35
| Professional | | $3,235.94 | $3,235.94 | $3,715.35 |
- 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 / $2,570.40 / $5,370.32
| Professional | | $1,778.28 | $2,570.40 | $5,370.32 |