- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,691.53 / $4,677.35
| Facility | | $2,137.96 | $2,691.53 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,754.23 / $4,570.88
| Professional | | $2,137.96 | $2,754.23 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,019.95 / $11,481.54
| Facility | | $2,187.76 | $3,019.95 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,951.21 / $6,456.54
| Professional | | $2,754.23 | $2,951.21 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $20,892.96
| Facility | | $3,548.13 | $3,548.13 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $7,943.28
| Professional | | $2,630.27 | $2,630.27 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,715.35 / $6,606.93
| Facility | | $3,162.28 | $3,715.35 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $4,073.80
| Professional | | $1,949.84 | $2,630.27 | $4,073.80 |