- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,304.11 / $2,734.31 / $7,962.32
| Facility | | $2,304.11 | $2,734.31 | $7,962.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.44 / $2,187.44 / $2,473.28
| Professional | | $2,187.44 | $2,187.44 | $2,473.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.63 / $3,849.91 / $5,745.70
| Professional | | $1,516.63 | $3,849.91 | $5,745.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,667.44 / $6,003.84 / $10,413.74
| Facility | | $1,667.44 | $6,003.84 | $10,413.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,916.60 / $2,916.60 / $14,058.01
| Professional | | $2,916.60 | $2,916.60 | $14,058.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,074.88 / $13,853.85 / $13,853.85
| Facility | | $5,074.88 | $13,853.85 | $13,853.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,583.00 / $14,583.00 / $21,874.50
| Professional | | $14,583.00 | $14,583.00 | $21,874.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,749.96 / $2,916.60
| Professional | | $1,224.97 | $1,749.96 | $2,916.60 |