- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,292.05 / $5,271.78 / $10,844.40
| Facility | | $3,292.05 | $5,271.78 | $10,844.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $3,175.86 / $4,326.92
| Professional | | $2,711.10 | $3,175.86 | $4,326.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,583.88 / $4,205.78 / $12,509.79
| Facility | | $3,583.88 | $4,205.78 | $12,509.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.20 / $2,013.96 / $3,873.00
| Professional | | $1,549.20 | $2,013.96 | $3,873.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,675.48 / $6,584.10 / $11,328.53
| Facility | | $3,675.48 | $6,584.10 | $11,328.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.23 / $3,569.74 / $6,597.17
| Professional | | $1,828.23 | $3,569.74 | $6,597.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,485.70 / $3,873.00 / $4,647.60
| Facility | | $3,485.70 | $3,873.00 | $4,647.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $4,453.95
| Professional | | $1,626.66 | $2,323.80 | $4,453.95 |