- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.34 / $5,475.80 / $12,496.30
| Facility | | $3,600.34 | $5,475.80 | $12,496.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,902.17 / $3,600.34 / $3,833.06
| Professional | | $2,902.17 | $3,600.34 | $3,833.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,841.80 / $8,035.74 / $13,552.61
| Facility | | $1,841.80 | $8,035.74 | $13,552.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,792.65 / $4,034.07 / $5,701.17
| Professional | | $2,792.65 | $4,034.07 | $5,701.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,559.27 / $15,183.09 / $31,429.02
| Facility | | $3,559.27 | $15,183.09 | $31,429.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,297.17 / $9,976.91 / $13,525.23
| Professional | | $6,297.17 | $9,976.91 | $13,525.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $3,285.48 / $9,609.48
| Professional | | $2,299.84 | $3,285.48 | $9,609.48 |