- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,773.62 / $3,766.28 / $8,122.91
| Facility | | $2,773.62 | $3,766.28 | $8,122.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.07 / $1,880.00 / $2,919.60
| Professional | | $719.07 | $1,880.00 | $2,919.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $4,290.33 / $7,820.64
| Facility | | $2,919.60 | $4,290.33 | $7,820.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.82 / $1,926.93 / $5,182.74
| Professional | | $1,313.82 | $1,926.93 | $5,182.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.88 / $2,922.52 / $9,786.89
| Facility | | $1,450.88 | $2,922.52 | $9,786.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,179.06 / $3,380.66 / $5,971.74
| Professional | | $2,179.06 | $3,380.66 | $5,971.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,343.02 / $2,890.40 / $3,941.46
| Professional | | $1,343.02 | $2,890.40 | $3,941.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,802.56 / $5,123.60
| Professional | | $1,226.23 | $1,802.56 | $5,123.60 |