- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,897.79 / $4,897.79
| Facility | | $2,818.38 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $4,073.80
| Professional | | $1,905.46 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,162.28 / $3,311.31
| Professional | | $2,089.30 | $3,162.28 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,691.53 / $3,801.89
| Professional | | $1,949.84 | $2,691.53 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,897.79 / $6,918.31
| Facility | | $2,818.38 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $3,630.78
| Professional | | $2,089.30 | $2,630.27 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $3,467.37
| Professional | | $2,187.76 | $2,951.21 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,890.45 / $6,025.60
| Facility | | $1,698.24 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $3,801.89
| Professional | | $2,238.72 | $2,691.53 | $3,801.89 |