- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,897.79 / $4,897.79
| Facility | | $3,090.30 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $4,265.80
| Professional | | $2,041.74 | $2,398.83 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,548.13 / $3,548.13
| Facility | | $2,238.72 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,548.13 / $3,715.35
| Professional | | $2,137.96 | $3,548.13 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $6,309.57
| Professional | | $1,949.84 | $2,818.38 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,897.79 / $7,585.78
| Facility | | $3,090.30 | $4,897.79 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $3,981.07
| Professional | | $2,290.87 | $2,818.38 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $4,677.35
| Professional | | $1,778.28 | $2,344.23 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,890.45 / $6,025.60
| Facility | | $1,230.27 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,754.23 / $3,548.13
| Professional | | $2,238.72 | $2,754.23 | $3,548.13 |