- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,349.55 / $4,170.46 / $5,537.50
| Facility | | $2,349.55 | $4,170.46 | $5,537.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,405.72 / $1,957.96 / $4,894.91
| Professional | | $1,405.72 | $1,957.96 | $4,894.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $815.82 / $2,510.21 / $6,024.50
| Facility | | $815.82 | $2,510.21 | $6,024.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.00 / $304.00 / $1,518.67
| Professional | | $304.00 | $304.00 | $1,518.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $2,936.95 / $9,088.23
| Facility | | $1,631.64 | $2,936.95 | $9,088.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,776.14 / $2,776.14 / $3,326.13
| Professional | | $2,776.14 | $2,776.14 | $3,326.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,510.21 / $2,635.72
| Professional | | $2,510.21 | $2,510.21 | $2,635.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,054.29 / $3,263.27
| Professional | | $1,054.29 | $1,054.29 | $3,263.27 |