- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,495.41 / $7,244.36
| Facility | | $4,786.30 | $5,495.41 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,073.80 / $5,495.41
| Professional | | $2,884.03 | $4,073.80 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $891.25
| Facility | | $549.54 | $660.69 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $3,090.30
| Professional | | $426.58 | $602.56 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,890.45 / $10,232.93
| Facility | | $3,090.30 | $3,890.45 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Professional | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,265.80 / $4,786.30
| Facility | | $1,995.26 | $4,265.80 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,884.03
| Professional | | $1,995.26 | $1,995.26 | $2,884.03 |