- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,226.06 / $3,292.72 / $3,398.17
| Facility | | $2,226.06 | $3,292.72 | $3,398.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,226.06 / $2,849.21 / $4,637.63
| Professional | | $2,226.06 | $2,849.21 | $4,637.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,872.41 / $5,116.03 / $22,491.04
| Facility | | $4,872.41 | $5,116.03 | $22,491.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,709.74 / $2,776.59 / $3,941.99
| Professional | | $2,709.74 | $2,776.59 | $3,941.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $2,853.06
| Facility | | $2,853.06 | $2,853.06 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,082.73 / $2,938.65
| Professional | | $2,082.73 | $2,082.73 | $2,938.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,226.06 / $3,926.77 / $24,371.76
| Facility | | $2,226.06 | $3,926.77 | $24,371.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.24 / $2,633.36 / $4,870.32
| Professional | | $1,898.24 | $2,633.36 | $4,870.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.05 / $2,430.79 / $3,510.16
| Professional | | $1,855.05 | $2,430.79 | $3,510.16 |