- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,311.31 / $6,760.83
| Facility | | $2,691.53 | $3,311.31 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $5,623.41
| Professional | | $2,691.53 | $3,467.37 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,890.45 / $14,791.08
| Facility | | $2,818.38 | $3,890.45 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,801.89 / $7,943.28
| Professional | | $3,388.44 | $3,801.89 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $25,118.86
| Facility | | $4,365.16 | $4,365.16 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $9,772.37
| Professional | | $3,162.28 | $3,162.28 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,677.35 / $8,511.38
| Facility | | $4,073.80 | $4,677.35 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,311.31 / $5,128.61
| Professional | | $2,454.71 | $3,311.31 | $5,128.61 |