- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,527.54 / $3,159.42 / $7,582.61
| Facility | | $2,527.54 | $3,159.42 | $7,582.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,369.57 / $2,369.57 / $2,527.54
| Professional | | $2,369.57 | $2,369.57 | $2,527.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,053.62 / $2,053.62 / $2,772.39
| Facility | | $2,053.62 | $2,053.62 | $2,772.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,848.09 / $3,848.09 / $4,610.43
| Professional | | $3,848.09 | $3,848.09 | $4,610.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,369.57 / $3,159.42 / $5,307.83
| Facility | | $2,369.57 | $3,159.42 | $5,307.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,326.96 / $11,864.35
| Professional | | $1,326.96 | $1,326.96 | $11,864.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.39 / $2,843.48 / $3,159.42
| Facility | | $1,137.39 | $2,843.48 | $3,159.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,326.96 / $3,159.42
| Professional | | $1,326.96 | $1,326.96 | $3,159.42 |