- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,235.94 / $9,772.37
| Facility | | $2,454.71 | $3,235.94 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,511.89 / $3,715.35
| Professional | | $2,187.76 | $2,511.89 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $8,709.64
| Facility | | $2,089.30 | $2,089.30 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,677.35
| Professional | | $3,981.07 | $3,981.07 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $5,623.41
| Facility | | $2,398.83 | $3,235.94 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $12,302.69
| Professional | | $1,348.96 | $1,348.96 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,235.94 / $3,890.45
| Facility | | $1,348.96 | $3,235.94 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $2,137.96
| Professional | | $1,348.96 | $1,348.96 | $2,137.96 |