- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,162.28 / $7,079.46
| Professional | | $2,570.40 | $3,162.28 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,365.16 / $7,943.28
| Facility | | $1,659.59 | $4,365.16 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,801.89 / $6,025.60
| Professional | | $2,951.21 | $3,801.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $5,754.40
| Professional | | $2,398.83 | $3,235.94 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $5,495.41
| Facility | | $2,290.87 | $3,162.28 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,548.13 / $20,892.96
| Professional | | $2,511.89 | $3,548.13 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,137.96 / $5,248.07
| Facility | | $831.76 | $2,137.96 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $5,370.32
| Professional | | $2,454.71 | $3,019.95 | $5,370.32 |