- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,131.22 / $9,245.62 / $9,245.62
| Facility | | $4,131.22 | $9,245.62 | $9,245.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,708.18 / $6,708.18 / $9,245.62
| Professional | | $6,708.18 | $6,708.18 | $9,245.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.09 / $2,916.60 / $3,740.08
| Facility | | $1,615.09 | $2,916.60 | $3,740.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.27 / $1,167.83 / $3,620.30
| Professional | | $934.27 | $1,167.83 | $3,620.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,916.60 / $4,229.07 / $6,268.63
| Facility | | $2,916.60 | $4,229.07 | $6,268.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,791.58 / $6,416.52 / $8,993.57
| Facility | | $3,791.58 | $6,416.52 | $8,993.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,333.28 / $16,416.80 / $16,416.80
| Professional | | $2,333.28 | $16,416.80 | $16,416.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,624.94 / $3,791.58 / $22,733.97
| Professional | | $2,624.94 | $3,791.58 | $22,733.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,383.26 / $3,908.24 / $5,395.71
| Professional | | $3,383.26 | $3,908.24 | $5,395.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,749.96 / $5,105.51
| Professional | | $1,224.97 | $1,749.96 | $5,105.51 |