- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,890.45 / $6,025.60
| Facility | | $3,162.28 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $3,890.45
| Professional | | $2,454.71 | $2,884.03 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $4,677.35
| Professional | | $3,467.37 | $3,715.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $60.26 / $12,302.69
| Professional | | $32.36 | $60.26 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,786.30 / $5,888.44
| Professional | | $3,235.94 | $4,786.30 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,888.44 / $8,128.31
| Professional | | $2,238.72 | $5,888.44 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,981.07 / $11,481.54
| Professional | | $3,467.37 | $3,981.07 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,128.61 / $13,803.84
| Facility | | $2,290.87 | $5,128.61 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,235.94 / $5,370.32
| Professional | | $2,511.89 | $3,235.94 | $5,370.32 |