- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,066.94 / $3,057.37 / $3,155.29
| Facility | | $2,066.94 | $3,057.37 | $3,155.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.94 / $2,368.38 / $4,306.14
| Professional | | $2,066.94 | $2,368.38 | $4,306.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,524.14 / $4,750.35 / $20,883.43
| Facility | | $4,524.14 | $4,750.35 | $20,883.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.79 / $2,731.58 / $3,721.30
| Professional | | $2,326.79 | $2,731.58 | $3,721.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $2,941.06
| Facility | | $2,941.06 | $2,941.06 | $2,941.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $2,146.96
| Professional | | $2,146.96 | $2,146.96 | $2,146.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,066.94 / $3,656.86 / $21,171.57
| Facility | | $2,066.94 | $3,656.86 | $21,171.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.53 / $2,445.14 / $4,016.33
| Professional | | $1,688.53 | $2,445.14 | $4,016.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.53 / $2,268.17 / $3,203.78
| Professional | | $1,688.53 | $2,268.17 | $3,203.78 |