- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,984.15 / $5,925.69 / $15,453.30
| Facility | | $2,984.15 | $5,925.69 | $15,453.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,575.55 / $2,904.75 / $3,292.05
| Professional | | $2,575.55 | $2,904.75 | $3,292.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,774.22 / $6,737.95 / $10,673.85
| Facility | | $1,774.22 | $6,737.95 | $10,673.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.26 / $3,262.93 / $15,804.81
| Professional | | $2,243.26 | $3,262.93 | $15,804.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,249.53 / $6,041.88 / $10,825.04
| Facility | | $2,249.53 | $6,041.88 | $10,825.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,594.91 / $3,873.00 / $7,372.85
| Facility | | $2,594.91 | $3,873.00 | $7,372.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $1,626.66 / $19,287.54
| Professional | | $1,626.66 | $1,626.66 | $19,287.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $1,626.66 / $2,323.80
| Professional | | $1,626.66 | $1,626.66 | $2,323.80 |