- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,995.14 / $4,193.18
| Facility | | $2,396.11 | $2,995.14 | $4,193.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,396.11 / $2,545.87
| Professional | | $2,396.11 | $2,396.11 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.96 / $4,286.22 / $8,167.18
| Facility | | $2,282.96 | $4,286.22 | $8,167.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.14 / $2,082.34 / $2,502.81
| Professional | | $1,902.14 | $2,082.34 | $2,502.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.02 / $2,545.87 / $2,545.87
| Professional | | $378.02 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,645.71 / $3,114.94 / $6,667.18
| Facility | | $2,645.71 | $3,114.94 | $6,667.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,645.71 / $3,174.85
| Professional | | $2,396.11 | $2,645.71 | $3,174.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $520.42 / $520.42
| Professional | | $30.00 | $520.42 | $520.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,778.52 / $3,095.27
| Professional | | $2,495.94 | $2,778.52 | $3,095.27 |