- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,215.29 / $4,755.96 / $4,908.26
| Facility | | $3,215.29 | $4,755.96 | $4,908.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,215.29 / $3,870.57 / $6,698.53
| Professional | | $3,215.29 | $3,870.57 | $6,698.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,037.63 / $7,389.51 / $32,485.70
| Facility | | $7,037.63 | $7,389.51 | $32,485.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,688.53 / $4,279.66 / $5,695.84
| Professional | | $3,688.53 | $4,279.66 | $5,695.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.47 / $4,697.47 / $4,697.47
| Facility | | $4,697.47 | $4,697.47 | $4,697.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $3,429.16
| Professional | | $3,429.16 | $3,429.16 | $3,429.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,272.17 / $5,971.07 / $35,737.98
| Facility | | $3,272.17 | $5,971.07 | $35,737.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,925.83 / $3,821.85 / $7,506.81
| Professional | | $2,925.83 | $3,821.85 | $7,506.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,749.08 / $3,537.68 / $5,410.34
| Professional | | $2,749.08 | $3,537.68 | $5,410.34 |