- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,315.07 / $3,424.37 / $3,534.03
| Facility | | $2,315.07 | $3,424.37 | $3,534.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,315.07 / $2,652.68 / $4,823.06
| Professional | | $2,315.07 | $2,652.68 | $4,823.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,067.22 / $5,320.58 / $23,390.29
| Facility | | $5,067.22 | $5,320.58 | $23,390.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,518.58 / $2,779.11 / $4,101.12
| Professional | | $2,518.58 | $2,779.11 | $4,101.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $3,294.10
| Facility | | $3,294.10 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $2,404.69 / $3,511.67
| Professional | | $2,404.69 | $2,404.69 | $3,511.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,315.07 / $4,083.77 / $23,712.81
| Facility | | $2,315.07 | $4,083.77 | $23,712.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.21 / $2,708.62 / $4,498.43
| Professional | | $1,891.21 | $2,708.62 | $4,498.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.21 / $2,527.98 / $3,588.36
| Professional | | $1,891.21 | $2,527.98 | $3,588.36 |