- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,676.56 / $3,959.07 / $4,085.86
| Facility | | $2,676.56 | $3,959.07 | $4,085.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,676.56 / $3,066.89 / $5,576.16
| Professional | | $2,676.56 | $3,066.89 | $5,576.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,858.45 / $6,151.37 / $27,042.61
| Facility | | $5,858.45 | $6,151.37 | $27,042.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.53 / $3,569.66 / $4,814.50
| Professional | | $699.53 | $3,569.66 | $4,814.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $3,728.42
| Facility | | $3,728.42 | $3,728.42 | $3,728.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $2,721.75 / $3,840.27
| Professional | | $2,721.75 | $2,721.75 | $3,840.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,290.82 / $5,272.61 / $26,807.65
| Facility | | $3,290.82 | $5,272.61 | $26,807.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.46 / $3,166.27 / $5,478.85
| Professional | | $2,230.46 | $3,166.27 | $5,478.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,135.42 / $2,922.71 / $4,296.37
| Professional | | $2,135.42 | $2,922.71 | $4,296.37 |