- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $8,511.38
| Facility | | $2,691.53 | $2,691.53 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,691.53 / $6,456.54
| Professional | | $2,137.96 | $2,691.53 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,888.44 / $7,079.46
| Professional | | $4,786.30 | $5,888.44 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,011.87 / $8,317.64
| Professional | | $3,090.30 | $5,011.87 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,311.31 / $5,248.07
| Facility | | $2,630.27 | $3,311.31 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,897.79 / $20,417.38
| Professional | | $2,884.03 | $4,897.79 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $33,884.42
| Facility | | $1,819.70 | $2,041.74 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,897.79 / $6,606.93
| Professional | | $2,884.03 | $4,897.79 | $6,606.93 |