- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,748.70 / $4,247.29 / $7,329.85
| Facility | | $2,748.70 | $4,247.29 | $7,329.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,401.16 / $2,717.10 / $3,064.64
| Professional | | $2,401.16 | $2,717.10 | $3,064.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.60 / $2,811.81 / $5,595.82
| Professional | | $1,239.60 | $2,811.81 | $5,595.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,351.62 / $6,101.31 / $7,530.62
| Facility | | $4,351.62 | $6,101.31 | $7,530.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,666.57 / $3,666.57 / $3,666.57
| Professional | | $3,666.57 | $3,666.57 | $3,666.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,685.51 / $3,791.30 / $15,007.25
| Facility | | $2,685.51 | $3,791.30 | $15,007.25 |
- 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 / $3,573.30
| Professional | | $1,326.96 | $1,895.65 | $3,573.30 |