- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,243.64 / $5,271.78 / $11,231.70
| Facility | | $3,243.64 | $5,271.78 | $11,231.70 |
- 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 / $4,540.32 / $13,400.58
| Facility | | $3,583.88 | $4,540.32 | $13,400.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.20 / $1,874.53 / $4,453.94
| Professional | | $1,549.20 | $1,874.53 | $4,453.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,565.97 / $6,520.19 / $11,390.13
| Facility | | $3,565.97 | $6,520.19 | $11,390.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,067.70 / $4,141.12 / $6,535.34
| Professional | | $2,067.70 | $4,141.12 | $6,535.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,679.35 / $3,679.35 / $4,647.60
| Facility | | $3,679.35 | $3,679.35 | $4,647.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $4,647.60
| Professional | | $1,626.66 | $2,323.80 | $4,647.60 |