- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,957.22 / $5,249.07 / $6,969.68
| Facility | | $2,957.22 | $5,249.07 | $6,969.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,769.28 / $2,464.35 / $6,160.87
| Professional | | $1,769.28 | $2,464.35 | $6,160.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.81 / $3,159.42 / $7,582.61
| Facility | | $1,026.81 | $3,159.42 | $7,582.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.00 / $1,296.00 / $1,911.44
| Professional | | $1,296.00 | $1,296.00 | $1,911.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,053.62 / $3,696.52 / $11,438.66
| Facility | | $2,053.62 | $3,696.52 | $11,438.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,848.09 / $3,848.09 / $4,610.43
| Professional | | $3,848.09 | $3,848.09 | $4,610.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.86 / $3,159.42 / $3,317.39
| Professional | | $789.86 | $3,159.42 | $3,317.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,326.96 / $3,159.42
| Professional | | $1,326.96 | $1,326.96 | $3,159.42 |