- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,207.94 / $3,265.93 / $3,370.53
| Facility | | $2,207.94 | $3,265.93 | $3,370.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.94 / $2,737.63 / $4,599.89
| Professional | | $2,207.94 | $2,737.63 | $4,599.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,832.77 / $5,074.41 / $22,308.07
| Facility | | $4,832.77 | $5,074.41 | $22,308.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,687.68 / $2,952.48 / $3,909.92
| Professional | | $2,687.68 | $2,952.48 | $3,909.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,578.08 / $3,578.08 / $3,578.08
| Facility | | $3,578.08 | $3,578.08 | $3,578.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $2,612.00
| Professional | | $2,612.00 | $2,612.00 | $2,612.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,247.02 / $3,894.83 / $25,854.57
| Facility | | $2,247.02 | $3,894.83 | $25,854.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,009.18 / $2,624.48 / $4,886.25
| Professional | | $2,009.18 | $2,624.48 | $4,886.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,839.96 / $2,611.92 / $3,817.44
| Professional | | $1,839.96 | $2,611.92 | $3,817.44 |