- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,386.41 / $2,079.61 / $3,868.50
| Facility | | $1,386.41 | $2,079.61 | $3,868.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.30 / $1,386.41 / $3,303.32
| Professional | | $804.30 | $1,386.41 | $3,303.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,893.49 / $2,893.49 / $3,472.19
| Facility | | $2,893.49 | $2,893.49 | $3,472.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,337.37 / $4,337.37 / $4,337.37
| Facility | | $4,337.37 | $4,337.37 | $4,337.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,140.74 / $4,584.78 / $5,712.67
| Professional | | $3,140.74 | $4,584.78 | $5,712.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,828.00 / $6,957.00
| Facility | | $1,565.00 | $2,828.00 | $6,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.37 / $3,587.42 / $5,841.22
| Professional | | $2,239.37 | $3,587.42 | $5,841.22 |