- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,165.54 / $4,682.35 / $4,832.32
| Facility | | $3,165.54 | $4,682.35 | $4,832.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,865.63 / $3,627.18 / $6,594.87
| Professional | | $2,865.63 | $3,627.18 | $6,594.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,928.73 / $7,275.17 / $31,983.02
| Facility | | $6,928.73 | $7,275.17 | $31,983.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,132.00 / $3,171.15 / $5,605.64
| Professional | | $3,132.00 | $3,171.15 | $5,605.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $3,745.37 / $3,745.37
| Facility | | $3,745.37 | $3,745.37 | $3,745.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $2,734.12
| Professional | | $2,734.12 | $2,734.12 | $2,734.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,903.87 / $5,411.39 / $27,462.75
| Facility | | $2,903.87 | $5,411.39 | $27,462.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,304.44 / $3,456.67 / $5,196.55
| Professional | | $2,304.44 | $3,456.67 | $5,196.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,304.44 / $3,456.67 / $4,906.58
| Professional | | $2,304.44 | $3,456.67 | $4,906.58 |