- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.21 / $9,813.00 / $14,552.94
| Facility | | $3,801.21 | $9,813.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,032.61 / $7,301.00 / $7,301.00
| Professional | | $7,032.61 | $7,301.00 | $7,301.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,605.00 / $1,932.86 / $10,440.43
| Facility | | $1,605.00 | $1,932.86 | $10,440.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,181.28 / $3,817.53 / $9,194.14
| Professional | | $3,181.28 | $3,817.53 | $9,194.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,738.75 / $5,310.90 / $7,199.22
| Professional | | $4,738.75 | $5,310.90 | $7,199.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.86 / $1,932.86 / $10,440.43
| Facility | | $1,932.86 | $1,932.86 | $10,440.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.73 / $6,426.75 / $8,685.29
| Professional | | $1,800.73 | $6,426.75 | $8,685.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.06 / $3,496.12 / $10,586.81
| Professional | | $1,527.06 | $3,496.12 | $10,586.81 |