- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,897.79 / $15,135.61
| Facility | | $3,311.31 | $4,897.79 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,168.69 / $5,011.87
| Professional | | $4,073.80 | $4,168.69 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,011.87 / $9,772.37
| Facility | | $1,698.24 | $5,011.87 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $4,168.69 / $5,128.61
| Professional | | $1,949.84 | $4,168.69 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $10,715.19
| Facility | | $4,265.80 | $4,265.80 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,265.80 / $5,011.87
| Professional | | $4,168.69 | $4,265.80 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,096.48 / $2,041.74
| Facility | | $1,023.29 | $1,096.48 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $5,011.87
| Professional | | $4,168.69 | $4,168.69 | $5,011.87 |