- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,370.32 / $9,549.93
| Facility | | $3,090.30 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $5,370.32
| Professional | | $2,398.83 | $3,235.94 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,888.44 / $12,022.64
| Facility | | $2,238.72 | $5,888.44 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,715.35 / $6,025.60
| Professional | | $2,398.83 | $3,715.35 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,365.16 / $7,413.10
| Professional | | $2,454.71 | $4,365.16 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,388.44 / $5,623.41
| Professional | | $3,019.95 | $3,388.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Professional | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $8,128.31
| Facility | | $1,047.13 | $3,235.94 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,235.94 / $7,244.36
| Professional | | $2,454.71 | $3,235.94 | $7,244.36 |