- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,073.80 / $4,365.16
| Facility | | $2,398.83 | $4,073.80 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,344.23 / $2,754.23
| Professional | | $2,041.74 | $2,344.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,570.40
| Facility | | $2,511.89 | $2,511.89 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Professional | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,677.35 / $8,709.64
| Facility | | $2,454.71 | $4,677.35 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $14,125.38
| Professional | | $14,125.38 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,318.26 / $3,630.78
| Professional | | $1,230.27 | $1,318.26 | $3,630.78 |