- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,311.31 / $5,495.41
| Facility | | $2,691.53 | $3,311.31 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,311.31 / $5,495.41
| Professional | | $2,691.53 | $3,311.31 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,548.13 / $13,182.57
| Facility | | $2,630.27 | $3,548.13 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,248.07 / $9,120.11
| Professional | | $3,235.94 | $5,248.07 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $26,915.35
| Facility | | $3,801.89 | $3,801.89 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $9,332.54
| Professional | | $3,235.94 | $3,235.94 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,365.16 / $7,762.47
| Facility | | $2,818.38 | $4,365.16 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $4,897.79
| Professional | | $2,344.23 | $3,162.28 | $4,897.79 |