- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,546.50 / $3,873.00 / $14,890.10
| Facility | | $2,546.50 | $3,873.00 | $14,890.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.69 / $2,546.50 / $3,650.00
| Professional | | $2,052.69 | $2,546.50 | $3,650.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,232.99 / $4,809.88 / $9,585.68
| Facility | | $3,232.99 | $4,809.88 | $9,585.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.85 / $2,885.38 / $6,008.57
| Professional | | $1,742.85 | $2,885.38 | $6,008.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,787.73 / $12,457.04 / $22,229.37
| Facility | | $5,787.73 | $12,457.04 | $22,229.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.12 / $4,484.39 / $15,252.16
| Professional | | $2,591.12 | $4,484.39 | $15,252.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $5,158.84 / $7,358.70
| Professional | | $2,711.10 | $5,158.84 | $7,358.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.58 / $2,323.80 / $6,796.73
| Professional | | $1,781.58 | $2,323.80 | $6,796.73 |