- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,890.45 / $5,128.61
| Facility | | $3,162.28 | $3,890.45 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $977.24 / $3,090.30
| Professional | | $323.59 | $977.24 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $338.84 / $407.38
| Professional | | $302.00 | $338.84 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $870.96 / $2,398.83
| Professional | | $302.00 | $870.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $2,691.53
| Professional | | $1,258.93 | $1,621.81 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $1,023.29 / $2,238.72
| Professional | | $295.12 | $1,023.29 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,659.59 / $2,238.72
| Professional | | $1,000.00 | $1,659.59 | $2,238.72 |