- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,715.35 / $4,265.80
| Facility | | $2,630.27 | $3,715.35 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $2,630.27
| Professional | | $1,445.44 | $1,819.70 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,318.26 / $3,467.37
| Professional | | $512.86 | $1,318.26 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,265.80 / $5,248.07
| Facility | | $2,884.03 | $4,265.80 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,630.27 / $10,471.29
| Facility | | $1,905.46 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $10,964.78
| Professional | | $933.25 | $1,318.26 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,187.76 / $2,630.27
| Facility | | $933.25 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,398.83
| Professional | | $933.25 | $1,318.26 | $2,398.83 |