- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,786.30 / $8,912.51
| Facility | | $3,467.37 | $4,786.30 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,786.30 / $8,128.31
| Professional | | $3,467.37 | $4,786.30 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,011.87 / $18,197.01
| Facility | | $3,715.35 | $5,011.87 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,897.79 / $10,471.29
| Professional | | $4,786.30 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $36,307.81
| Facility | | $6,309.57 | $6,309.57 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $14,125.38
| Professional | | $4,570.88 | $4,570.88 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,025.60 / $10,964.78
| Facility | | $3,630.78 | $6,025.60 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,466.84 / $6,760.83
| Professional | | $3,235.94 | $4,466.84 | $6,760.83 |