- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $16,595.87
| Facility | | $2,754.23 | $3,715.35 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,818.38 / $4,677.35
| Professional | | $2,570.40 | $2,818.38 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $9,772.37
| Facility | | $2,398.83 | $2,398.83 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $5,370.32
| Professional | | $4,466.84 | $4,466.84 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,715.35 / $6,456.54
| Facility | | $2,691.53 | $3,715.35 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $13,803.84
| Professional | | $1,548.82 | $1,548.82 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,715.35 / $4,365.16
| Facility | | $1,548.82 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,398.83
| Professional | | $1,548.82 | $1,548.82 | $2,398.83 |