- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.19 / $3,176.06 / $3,277.76
| Facility | | $2,147.19 | $3,176.06 | $3,277.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.19 / $2,522.19 / $4,473.33
| Professional | | $2,147.19 | $2,522.19 | $4,473.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,148.86 / $3,148.86 / $3,148.86
| Professional | | $3,148.86 | $3,148.86 | $3,148.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,699.79 / $4,934.78 / $21,694.23
| Facility | | $4,699.79 | $4,934.78 | $21,694.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,434.85 / $3,043.56 / $3,846.29
| Professional | | $2,434.85 | $3,043.56 | $3,846.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $3,001.57
| Facility | | $3,001.57 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $2,191.15 / $3,199.83
| Professional | | $2,191.15 | $2,191.15 | $3,199.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,657.16 / $4,076.73 / $21,089.02
| Facility | | $2,657.16 | $4,076.73 | $21,089.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.33 / $2,542.29 / $4,222.92
| Professional | | $1,789.33 | $2,542.29 | $4,222.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.92 / $2,344.67 / $3,396.52
| Professional | | $1,645.92 | $2,344.67 | $3,396.52 |