- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,743.10 / $3,428.88 / $6,379.40
| Facility | | $2,743.10 | $3,428.88 | $6,379.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,743.10 / $2,743.10 / $3,130.56
| Professional | | $2,743.10 | $2,743.10 | $3,130.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,194.62 / $4,857.58 / $7,972.15
| Facility | | $2,194.62 | $4,857.58 | $7,972.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.00 / $2,571.66 / $3,428.88
| Professional | | $165.00 | $2,571.66 | $3,428.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $2,914.55
| Facility | | $2,914.55 | $2,914.55 | $2,914.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $2,914.55
| Professional | | $2,914.55 | $2,914.55 | $2,914.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,743.10 / $3,943.21 / $15,144.20
| Facility | | $2,743.10 | $3,943.21 | $15,144.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,585.94 / $2,857.40 / $3,563.18
| Professional | | $2,585.94 | $2,857.40 | $3,563.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,800.25 / $2,857.40 / $3,360.30
| Professional | | $2,800.25 | $2,857.40 | $3,360.30 |