- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,429.89 / $3,002.06 / $5,955.31
| Facility | | $2,429.89 | $3,002.06 | $5,955.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,648.58
| Professional | | $2,429.89 | $2,429.89 | $2,648.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,292.35 / $2,628.25 / $3,401.27
| Facility | | $2,292.35 | $2,628.25 | $3,401.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,521.59
| Professional | | $2,429.89 | $2,429.89 | $2,521.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,341.61 / $2,341.61 / $2,974.42
| Professional | | $2,341.61 | $2,341.61 | $2,974.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,441.48 / $4,903.52 / $13,785.00
| Facility | | $2,441.48 | $4,903.52 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.32 / $2,326.02 / $2,352.56
| Professional | | $2,195.32 | $2,326.02 | $2,352.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,978.62 / $2,978.62 / $2,978.62
| Facility | | $2,978.62 | $2,978.62 | $2,978.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,563.53 / $2,825.48
| Professional | | $2,429.89 | $2,563.53 | $2,825.48 |