- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,114.07 / $4,606.22 / $4,753.75
| Facility | | $3,114.07 | $4,606.22 | $4,753.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,114.07 / $3,568.20 / $6,487.64
| Professional | | $3,114.07 | $3,568.20 | $6,487.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,816.07 / $7,156.87 / $31,462.98
| Facility | | $6,816.07 | $7,156.87 | $31,462.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,326.19 / $3,688.79 / $5,514.49
| Professional | | $3,326.19 | $3,688.79 | $5,514.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,790.37 / $3,790.37 / $3,790.37
| Facility | | $3,790.37 | $3,790.37 | $3,790.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.97 / $2,766.97 / $3,904.08
| Professional | | $2,766.97 | $2,766.97 | $3,904.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,114.07 / $5,493.22 / $32,412.74
| Facility | | $3,114.07 | $5,493.22 | $32,412.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,521.88 / $3,643.46 / $5,931.71
| Professional | | $2,521.88 | $3,643.46 | $5,931.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,521.88 / $3,400.46 / $4,826.80
| Professional | | $2,521.88 | $3,400.46 | $4,826.80 |