- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,195.23 / $5,206.57 / $10,108.50
| Facility | | $3,195.23 | $5,206.57 | $10,108.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $3,137.13 / $3,873.00
| Professional | | $2,711.10 | $3,137.13 | $3,873.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,583.88 / $4,205.78 / $13,400.58
| Facility | | $3,583.88 | $4,205.78 | $13,400.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.20 / $1,642.15 / $5,010.11
| Professional | | $1,549.20 | $1,642.15 | $5,010.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,768.22 / $5,906.80 / $11,725.02
| Facility | | $2,768.22 | $5,906.80 | $11,725.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.62 / $3,493.42 / $6,441.17
| Professional | | $1,968.62 | $3,493.42 | $6,441.17 |
- 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 |