- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,510.21 / $5,334.20
| Facility | | $2,510.21 | $2,510.21 | $5,334.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,033.27 / $2,033.27 / $2,033.27
| Professional | | $2,033.27 | $2,033.27 | $2,033.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,429.13 / $3,049.15 / $8,677.79
| Facility | | $2,429.13 | $3,049.15 | $8,677.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.08 / $1,004.08 / $1,631.63
| Professional | | $1,004.08 | $1,004.08 | $1,631.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,949.13 / $5,949.13 / $5,949.13
| Facility | | $5,949.13 | $5,949.13 | $5,949.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,510.21 / $2,535.31
| Professional | | $2,510.21 | $2,510.21 | $2,535.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,510.21 / $4,066.54
| Facility | | $2,510.21 | $2,510.21 | $4,066.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,033.27 / $2,033.27 / $2,510.21
| Professional | | $2,033.27 | $2,033.27 | $2,510.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.13 / $1,673.47 / $4,183.68
| Professional | | $1,506.13 | $1,673.47 | $4,183.68 |