- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,848.18 / $6,528.63 / $10,088.00
| Facility | | $3,848.18 | $6,528.63 | $10,088.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,369.57 / $2,748.70 / $3,159.42
| Professional | | $2,369.57 | $2,748.70 | $3,159.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,949.28 / $3,949.28 / $3,949.28
| Professional | | $3,949.28 | $3,949.28 | $3,949.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,792.92 / $5,175.12 / $7,163.72
| Facility | | $2,792.92 | $5,175.12 | $7,163.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,527.54 / $3,159.42 / $4,250.39
| Facility | | $2,527.54 | $3,159.42 | $4,250.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,895.65 / $15,733.91
| Professional | | $1,326.96 | $1,895.65 | $15,733.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,895.65 / $4,739.13
| Professional | | $1,326.96 | $1,895.65 | $4,739.13 |