- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,370.32 / $9,549.93
| Facility | | $3,311.31 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,951.21 / $5,370.32
| Professional | | $2,454.71 | $2,951.21 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Professional | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $6,309.57 / $12,302.69
| Facility | | $2,238.72 | $6,309.57 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,981.07 / $5,623.41
| Professional | | $2,344.23 | $3,981.07 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,265.80 / $7,413.10
| Professional | | $2,570.40 | $4,265.80 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,801.89 / $5,248.07
| Professional | | $2,951.21 | $3,801.89 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,235.94 / $7,943.28
| Facility | | $602.56 | $3,235.94 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,388.44 / $7,244.36
| Professional | | $2,511.89 | $3,388.44 | $7,244.36 |