- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,175.86 / $5,083.30 / $10,556.20
| Facility | | $3,175.86 | $5,083.30 | $10,556.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $3,137.13 / $3,640.62
| Professional | | $2,711.10 | $3,137.13 | $3,640.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.73 / $3,873.00 / $15,104.70
| Facility | | $1,258.73 | $3,873.00 | $15,104.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.40 / $1,148.40 / $2,517.44
| Professional | | $1,148.40 | $1,148.40 | $2,517.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.85 / $6,513.90 / $11,887.15
| Facility | | $3,044.85 | $6,513.90 | $11,887.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,647.60 / $4,717.52 / $5,652.12
| Professional | | $4,647.60 | $4,717.52 | $5,652.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,647.60 / $4,647.60 / $4,647.60
| Facility | | $4,647.60 | $4,647.60 | $4,647.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $4,453.95
| Professional | | $1,626.66 | $2,323.80 | $4,453.95 |