- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,791.70 / $5,792.79 / $7,649.26
| Facility | | $2,791.70 | $5,792.79 | $7,649.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,320.60 / $2,791.70 / $2,966.19
| Professional | | $2,320.60 | $2,791.70 | $2,966.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,651.60 / $3,402.39 / $9,161.39
| Facility | | $2,651.60 | $3,402.39 | $9,161.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,791.70 / $3,489.63 / $5,234.45
| Facility | | $2,791.70 | $3,489.63 | $5,234.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,268.26 / $2,268.26 / $3,489.63
| Professional | | $2,268.26 | $2,268.26 | $3,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,489.63 / $5,339.13 / $6,682.64
| Professional | | $3,489.63 | $5,339.13 | $6,682.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.82 / $2,093.78 / $3,594.32
| Professional | | $1,744.82 | $2,093.78 | $3,594.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,071.96 / $16,575.74 / $16,575.74
| Facility | | $6,071.96 | $16,575.74 | $16,575.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,378.36 / $17,378.36 / $26,172.23
| Professional | | $17,378.36 | $17,378.36 | $26,172.23 |