- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.92 / $8,303.41 / $13,413.92
| Facility | | $2,016.92 | $8,303.41 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,287.47 / $3,287.47 / $4,361.32
| Professional | | $3,287.47 | $3,287.47 | $4,361.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,289.46 / $2,289.46 / $2,289.46
| Professional | | $2,289.46 | $2,289.46 | $2,289.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $833.65 / $3,287.47 / $4,701.08
| Facility | | $833.65 | $3,287.47 | $4,701.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,714.38 / $4,452.00 / $5,501.86
| Professional | | $1,714.38 | $4,452.00 | $5,501.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.00 / $3,074.00 / $4,554.00
| Professional | | $2,650.00 | $3,074.00 | $4,554.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $833.65 / $3,287.47 / $4,701.08
| Facility | | $833.65 | $3,287.47 | $4,701.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.45 / $3,054.00 / $4,598.26
| Professional | | $979.45 | $3,054.00 | $4,598.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.69 / $1,837.82 / $4,268.52
| Professional | | $1,783.69 | $1,837.82 | $4,268.52 |