- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,877.10 / $7,346.37 / $12,841.80
| Facility | | $5,877.10 | $7,346.37 | $12,841.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.78 / $2,372.94 / $3,280.25
| Professional | | $2,093.78 | $2,372.94 | $3,280.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.72 / $10,050.12 / $16,838.86
| Facility | | $4,466.72 | $10,050.12 | $16,838.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $1,465.64 / $3,489.63
| Professional | | $1,465.64 | $1,465.64 | $3,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.07 / $2,336.31 / $10,660.82
| Facility | | $1,996.07 | $2,336.31 | $10,660.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,273.92 / $4,273.92 / $5,059.96
| Professional | | $4,273.92 | $4,273.92 | $5,059.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,652.12 / $3,489.63 / $4,885.47
| Facility | | $2,652.12 | $3,489.63 | $4,885.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,791.70 / $4,885.47 / $6,979.26
| Professional | | $2,791.70 | $4,885.47 | $6,979.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $1,465.64 / $2,093.78
| Professional | | $1,465.64 | $1,465.64 | $2,093.78 |