- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,011.87 / $5,011.87
| Facility | | $3,467.37 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,570.40 / $6,025.60
| Professional | | $1,995.26 | $2,570.40 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,302.69 / $13,803.84
| Facility | | $7,413.10 | $12,302.69 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,466.84 / $5,754.40
| Professional | | $2,754.23 | $4,466.84 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,981.07 / $5,888.44
| Professional | | $3,019.95 | $3,981.07 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,365.16 / $6,606.93
| Professional | | $2,691.53 | $4,365.16 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,165.95 / $15,135.61
| Facility | | $3,311.31 | $6,165.95 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,467.37 / $5,248.07
| Professional | | $2,398.83 | $3,467.37 | $5,248.07 |