- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,197.67 / $4,729.89 / $4,881.37
| Facility | | $3,197.67 | $4,729.89 | $4,881.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,197.67 / $3,664.00 / $6,661.82
| Professional | | $3,197.67 | $3,664.00 | $6,661.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,999.07 / $7,349.02 / $32,307.71
| Facility | | $6,999.07 | $7,349.02 | $32,307.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,428.56 / $3,804.46 / $5,662.55
| Professional | | $3,428.56 | $3,804.46 | $5,662.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,366.38 / $4,366.38 / $4,366.38
| Facility | | $4,366.38 | $4,366.38 | $4,366.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.46 / $3,187.46 / $4,497.37
| Professional | | $3,187.46 | $3,187.46 | $4,497.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,197.67 / $5,640.69 / $33,390.44
| Facility | | $3,197.67 | $5,640.69 | $33,390.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.04 / $3,741.26 / $5,962.77
| Professional | | $2,589.04 | $3,741.26 | $5,962.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.04 / $3,518.29 / $5,414.38
| Professional | | $2,589.04 | $3,518.29 | $5,414.38 |