- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,388.44 / $6,025.60
| Facility | | $2,691.53 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,995.26 / $2,818.38
| Professional | | $1,548.82 | $1,995.26 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,398.83 / $2,691.53
| Professional | | $2,238.72 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $5,370.32
| Professional | | $32.36 | $33.11 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,801.89 / $5,128.61
| Professional | | $2,089.30 | $3,801.89 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,715.35 / $5,128.61
| Professional | | $1,445.44 | $3,715.35 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $3,715.35
| Professional | | $2,187.76 | $2,570.40 | $3,715.35 |
- 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
- $1,621.81 / $2,089.30 / $3,388.44
| Professional | | $1,621.81 | $2,089.30 | $3,388.44 |