- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.91 / $2,571.91 / $3,426.43
| Facility | | $2,571.91 | $2,571.91 | $3,426.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,537.62 / $2,665.43 / $4,068.29
| Professional | | $2,537.62 | $2,665.43 | $4,068.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,912.93 / $5,158.58 / $22,678.08
| Facility | | $4,912.93 | $5,158.58 | $22,678.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,441.91 / $2,853.99 / $3,976.24
| Professional | | $2,441.91 | $2,853.99 | $3,976.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $2,012.35
| Professional | | $2,012.35 | $2,012.35 | $2,012.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,459.58 / $3,976.56 / $22,996.26
| Facility | | $2,459.58 | $3,976.56 | $22,996.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.45 / $2,451.01 / $5,971.64
| Professional | | $1,823.45 | $2,451.01 | $5,971.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.29 / $2,451.01 / $3,730.06
| Professional | | $1,723.29 | $2,451.01 | $3,730.06 |