- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,370.32 / $7,943.28
| Facility | | $2,754.23 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $2,754.23
| Professional | | $1,621.81 | $2,137.96 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,265.80 / $4,897.79
| Professional | | $3,162.28 | $4,265.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,905.46 / $3,162.28
| Professional | | $151.36 | $1,905.46 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,677.35 / $7,244.36
| Facility | | $2,344.23 | $4,677.35 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,311.31 / $5,495.41
| Professional | | $1,621.81 | $3,311.31 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,365.16 / $4,897.79
| Professional | | $3,162.28 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,691.53 / $5,495.41
| Professional | | $1,584.89 | $2,691.53 | $5,495.41 |