- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,388.44 / $6,025.60
| Facility | | $3,162.28 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,691.53 / $6,025.60
| Professional | | $2,137.96 | $2,691.53 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,235.94 / $5,495.41
| Professional | | $2,089.30 | $3,235.94 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $7,079.46
| Professional | | $32.36 | $33.11 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,623.41 / $8,128.31
| Professional | | $3,981.07 | $5,623.41 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,888.44 / $7,585.78
| Professional | | $2,511.89 | $5,888.44 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,466.84 / $5,888.44
| Professional | | $3,801.89 | $4,466.84 | $5,888.44 |
- 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
- $2,187.76 / $2,818.38 / $5,128.61
| Professional | | $2,187.76 | $2,818.38 | $5,128.61 |