- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,760.83 / $16,218.10
| Facility | | $3,162.28 | $6,760.83 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $4,897.79
| Professional | | $2,570.40 | $3,311.31 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,011.87 / $17,782.79
| Facility | | $3,467.37 | $5,011.87 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,548.82 / $5,754.40
| Professional | | $794.33 | $1,548.82 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,413.10 / $16,218.10
| Facility | | $2,511.89 | $7,413.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $4,677.35 / $9,332.54
| Professional | | $1,862.09 | $4,677.35 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $4,677.35
| Facility | | $2,041.74 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $4,570.88
| Professional | | $1,513.56 | $2,041.74 | $4,570.88 |