- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,061.75 / $3,049.67 / $3,147.35
| Facility | | $2,061.75 | $3,049.67 | $3,147.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,061.75 / $2,362.42 / $4,295.31
| Professional | | $2,061.75 | $2,362.42 | $4,295.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,512.76 / $4,738.39 / $20,830.90
| Facility | | $4,512.76 | $4,738.39 | $20,830.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.32 / $2,262.55 / $3,651.01
| Professional | | $2,224.32 | $2,262.55 | $3,651.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.85 / $2,970.85 / $2,970.85
| Facility | | $2,970.85 | $2,970.85 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,168.71 / $3,167.07
| Professional | | $2,168.71 | $2,168.71 | $3,167.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,061.75 / $3,636.93 / $19,143.40
| Facility | | $2,061.75 | $3,636.93 | $19,143.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.69 / $2,412.26 / $3,724.34
| Professional | | $1,539.69 | $2,412.26 | $3,724.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.69 / $2,251.37 / $3,195.71
| Professional | | $1,539.69 | $2,251.37 | $3,195.71 |