- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,370.32 / $7,943.28
| Facility | | $3,630.78 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,019.95 / $5,754.40
| Professional | | $2,344.23 | $3,019.95 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,073.80 / $11,220.18
| Facility | | $1,513.56 | $4,073.80 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,073.80 / $6,025.60
| Professional | | $2,511.89 | $4,073.80 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,786.30 / $4,786.30
| Facility | | $1,202.26 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,265.80 / $7,079.46
| Professional | | $2,754.23 | $4,265.80 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $15,848.93
| Professional | | $2,884.03 | $3,801.89 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $7,413.10 / $17,378.01
| Facility | | $1,995.26 | $7,413.10 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,467.37 / $6,309.57
| Professional | | $2,344.23 | $3,467.37 | $6,309.57 |