- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,460.75 / $3,639.86 / $3,756.42
| Facility | | $2,460.75 | $3,639.86 | $3,756.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.75 / $3,115.83 / $5,126.56
| Professional | | $2,460.75 | $3,115.83 | $5,126.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,386.09 / $5,655.39 / $24,862.19
| Facility | | $5,386.09 | $5,655.39 | $24,862.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,995.41 / $3,205.32 / $4,357.58
| Professional | | $2,995.41 | $3,205.32 | $4,357.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,072.36 / $4,072.36
| Facility | | $4,072.36 | $4,072.36 | $4,072.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $2,972.82 / $4,194.53
| Professional | | $2,972.82 | $2,972.82 | $4,194.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,460.75 / $4,340.75 / $28,628.31
| Facility | | $2,460.75 | $4,340.75 | $28,628.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.73 / $2,924.96 / $5,592.31
| Professional | | $2,218.73 | $2,924.96 | $5,592.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.69 / $2,687.06 / $4,102.81
| Professional | | $2,084.69 | $2,687.06 | $4,102.81 |