- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,897.79 / $10,471.29
| Facility | | $3,715.35 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,041.74 / $5,128.61
| Professional | | $1,659.59 | $2,041.74 | $5,128.61 |
- 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
- $1,905.46 / $3,311.31 / $4,073.80
| Professional | | $1,905.46 | $3,311.31 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,019.95 / $5,248.07
| Professional | | $2,238.72 | $3,019.95 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,890.45
| Professional | | $3,019.95 | $3,019.95 | $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
- $1,862.09 / $2,691.53 / $5,623.41
| Professional | | $1,862.09 | $2,691.53 | $5,623.41 |