- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,529.08 / $5,708.80 / $15,453.30
| Facility | | $3,529.08 | $5,708.80 | $15,453.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,575.55 / $2,904.75 / $3,292.05
| Professional | | $2,575.55 | $2,904.75 | $3,292.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,604.46 / $9,890.99 / $15,668.71
| Facility | | $2,604.46 | $9,890.99 | $15,668.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,871.97 / $2,722.87 / $13,188.91
| Professional | | $1,871.97 | $2,722.87 | $13,188.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,827.02 / $6,797.12 / $11,328.53
| Facility | | $2,827.02 | $6,797.12 | $11,328.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,594.91 / $3,873.00 / $6,990.49
| Facility | | $2,594.91 | $3,873.00 | $6,990.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $1,626.66 / $19,365.00
| Professional | | $1,626.66 | $1,626.66 | $19,365.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $1,626.66 / $2,323.80
| Professional | | $1,626.66 | $1,626.66 | $2,323.80 |