- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,015.76 / $4,015.76 / $5,724.21
| Facility | | $4,015.76 | $4,015.76 | $5,724.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.14 / $4,293.16 / $4,293.16
| Professional | | $1,541.14 | $4,293.16 | $4,293.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,586.29 / $8,586.29 / $8,586.29
| Facility | | $8,586.29 | $8,586.29 | $8,586.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.76 / $2,529.63 / $3,162.03
| Professional | | $2,090.76 | $2,529.63 | $3,162.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,091.54 / $4,293.16 / $4,550.75
| Facility | | $2,091.54 | $4,293.16 | $4,550.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.62 / $2,201.62 / $2,641.94
| Professional | | $2,201.62 | $2,201.62 | $2,641.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,302.43 / $5,504.05 / $7,925.83
| Facility | | $3,302.43 | $5,504.05 | $7,925.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,871.38 / $3,290.47 / $3,290.47
| Professional | | $1,871.38 | $3,290.47 | $3,290.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.68 / $924.68 / $2,641.94
| Professional | | $924.68 | $924.68 | $2,641.94 |