- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,526.01 / $4,275.73 / $8,074.63
| Facility | | $2,526.01 | $4,275.73 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.17 / $2,762.41 / $4,869.77
| Professional | | $2,586.17 | $2,762.41 | $4,869.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,105.25 / $16,184.00 / $28,925.33
| Facility | | $8,105.25 | $16,184.00 | $28,925.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,706.87 / $3,620.71 / $5,715.39
| Professional | | $2,706.87 | $3,620.71 | $5,715.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.08 / $3,453.08 / $4,844.20
| Facility | | $3,453.08 | $3,453.08 | $4,844.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,863.90 / $4,198.04 / $6,389.72
| Professional | | $2,863.90 | $4,198.04 | $6,389.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,403.00 / $3,325.00 / $8,198.00
| Facility | | $1,403.00 | $3,325.00 | $8,198.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,760.98 / $3,833.48 / $6,517.86
| Professional | | $2,760.98 | $3,833.48 | $6,517.86 |