- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,073.80 / $7,585.78
| Facility | | $3,090.30 | $4,073.80 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,073.80 / $7,413.10
| Professional | | $3,162.28 | $4,073.80 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,365.16 / $14,454.40
| Facility | | $3,235.94 | $4,365.16 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,265.80 / $9,332.54
| Professional | | $4,168.69 | $4,265.80 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $27,542.29
| Facility | | $4,677.35 | $4,677.35 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $10,471.29
| Professional | | $3,467.37 | $3,467.37 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,248.07 / $9,549.93
| Facility | | $2,951.21 | $5,248.07 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,168.69 / $5,888.44
| Professional | | $2,951.21 | $4,168.69 | $5,888.44 |