- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,370.32 / $7,943.28
| Facility | | $3,548.13 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,884.03 / $5,370.32
| Professional | | $2,344.23 | $2,884.03 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,370.32 / $11,220.18
| Facility | | $2,187.76 | $5,370.32 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,073.80 / $6,025.60
| Professional | | $2,570.40 | $4,073.80 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $2,511.89 / $4,677.35
| Facility | | $501.19 | $2,511.89 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,265.80 / $7,079.46
| Professional | | $2,570.40 | $4,265.80 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,548.13 / $15,135.61
| Professional | | $2,754.23 | $3,548.13 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $7,762.47 / $17,378.01
| Facility | | $1,995.26 | $7,762.47 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,467.37 / $6,025.60
| Professional | | $2,344.23 | $3,467.37 | $6,025.60 |