- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,586.16 / $3,825.37 / $3,947.87
| Facility | | $2,586.16 | $3,825.37 | $3,947.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.16 / $2,963.31 / $5,387.84
| Professional | | $2,586.16 | $2,963.31 | $5,387.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,660.59 / $5,943.62 / $26,129.28
| Facility | | $5,660.59 | $5,943.62 | $26,129.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.59 / $2,872.13 / $4,579.66
| Professional | | $2,823.59 | $2,872.13 | $4,579.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,798.08 / $3,798.08 / $3,798.08
| Facility | | $3,798.08 | $3,798.08 | $3,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $2,772.60 / $4,048.94
| Professional | | $2,772.60 | $2,772.60 | $4,048.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,586.16 / $4,561.97 / $24,802.46
| Facility | | $2,586.16 | $4,561.97 | $24,802.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.51 / $3,025.80 / $5,014.68
| Professional | | $1,954.51 | $3,025.80 | $5,014.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.51 / $2,824.01 / $3,782.25
| Professional | | $1,954.51 | $2,824.01 | $3,782.25 |