- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,380.16 / $9,088.83 / $12,001.60
| Facility | | $4,380.16 | $9,088.83 | $12,001.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,641.01 / $4,380.16 / $4,653.92
| Professional | | $3,641.01 | $4,380.16 | $4,653.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,160.33 / $5,338.32 / $14,373.73
| Facility | | $4,160.33 | $5,338.32 | $14,373.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,380.16 / $5,475.20 / $8,212.79
| Facility | | $4,380.16 | $5,475.20 | $8,212.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,558.88 / $3,558.88 / $5,475.20
| Professional | | $3,558.88 | $3,558.88 | $5,475.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,022.72 / $8,377.06 / $10,485.01
| Professional | | $6,022.72 | $8,377.06 | $10,485.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,737.60 / $3,285.12 / $5,639.46
| Professional | | $2,737.60 | $3,285.12 | $5,639.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,526.85 / $26,007.20 / $26,007.20
| Facility | | $9,526.85 | $26,007.20 | $26,007.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,266.50 / $27,266.50 / $41,064.00
| Professional | | $27,266.50 | $27,266.50 | $41,064.00 |