- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,370.32 / $7,943.28
| Facility | | $3,162.28 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $4,786.30
| Professional | | $1,862.09 | $2,630.27 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $8,511.38 / $10,715.19
| Professional | | $5,888.44 | $8,511.38 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,466.84 / $10,964.78
| Professional | | $2,754.23 | $4,466.84 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,370.32 / $7,413.10
| Facility | | $2,137.96 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,715.35 / $6,309.57
| Professional | | $1,949.84 | $3,715.35 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,370.32 / $6,025.60
| Professional | | $3,311.31 | $5,370.32 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Professional | | $5,888.44 | $5,888.44 | $5,888.44 |
- 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
- $1,862.09 / $2,818.38 / $5,754.40
| Professional | | $1,862.09 | $2,818.38 | $5,754.40 |