- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $6,456.54 / $16,982.44
| Facility | | $3,090.30 | $6,456.54 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,884.03 / $3,715.35
| Professional | | $2,290.87 | $2,884.03 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $6,165.95 / $18,620.87
| Facility | | $3,090.30 | $6,165.95 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,659.59 / $4,897.79
| Professional | | $1,513.56 | $1,659.59 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,025.60 / $15,488.17
| Facility | | $2,398.83 | $6,025.60 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $10,964.78
| Professional | | $4,265.80 | $5,370.32 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,715.35 / $4,365.16
| Facility | | $2,187.76 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $4,365.16
| Professional | | $1,548.82 | $2,187.76 | $4,365.16 |