- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,623.41 / $7,943.28
| Facility | | $3,467.37 | $5,623.41 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,630.27 / $5,011.87
| Professional | | $2,187.76 | $2,630.27 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,801.89 / $6,918.31
| Facility | | $1,412.54 | $3,801.89 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,801.89 / $5,495.41
| Professional | | $2,511.89 | $3,801.89 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $2,511.89 / $4,168.69
| Facility | | $501.19 | $2,511.89 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,890.45 / $6,309.57
| Professional | | $2,570.40 | $3,890.45 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,548.13 / $13,803.84
| Professional | | $2,454.71 | $3,548.13 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,918.31 / $12,022.64
| Facility | | $1,737.80 | $6,918.31 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,235.94 / $5,495.41
| Professional | | $2,137.96 | $3,235.94 | $5,495.41 |