- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,262.81 / $3,347.07 / $3,454.25
| Facility | | $2,262.81 | $3,347.07 | $3,454.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.81 / $2,592.80 / $4,714.18
| Professional | | $2,262.81 | $2,592.80 | $4,714.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,952.83 / $5,200.47 / $22,862.26
| Facility | | $4,952.83 | $5,200.47 | $22,862.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,416.92 / $2,704.43 / $4,007.05
| Professional | | $2,416.92 | $2,704.43 | $4,007.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $2,780.72
| Facility | | $2,780.72 | $2,780.72 | $2,780.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,029.93 / $2,964.38
| Professional | | $2,029.93 | $2,029.93 | $2,964.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,262.81 / $3,991.58 / $23,421.34
| Facility | | $2,262.81 | $3,991.58 | $23,421.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.11 / $2,647.48 / $4,162.43
| Professional | | $1,850.11 | $2,647.48 | $4,162.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.11 / $2,470.91 / $3,507.35
| Professional | | $1,850.11 | $2,470.91 | $3,507.35 |