- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,915.42 / $6,949.87 / $9,227.99
| Facility | | $3,915.42 | $6,949.87 | $9,227.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,342.56 / $3,262.85 / $8,157.11
| Professional | | $2,342.56 | $3,262.85 | $8,157.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,359.52 / $4,183.13 / $10,039.51
| Facility | | $1,359.52 | $4,183.13 | $10,039.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.00 / $208.00 / $2,166.86
| Professional | | $208.00 | $208.00 | $2,166.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,719.03 / $4,894.25 / $6,797.58
| Facility | | $2,719.03 | $4,894.25 | $6,797.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,095.32 / $5,095.32 / $6,104.77
| Professional | | $5,095.32 | $5,095.32 | $6,104.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,183.13 / $4,183.13 / $4,392.29
| Professional | | $4,183.13 | $4,183.13 | $4,392.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.91 / $1,756.91 / $4,183.13
| Professional | | $1,756.91 | $1,756.91 | $4,183.13 |