- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,523.41 / $2,968.59 / $3,505.08
| Facility | | $2,523.41 | $2,968.59 | $3,505.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.85 / $2,523.41 / $3,350.88
| Professional | | $1,708.85 | $2,523.41 | $3,350.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,430.62 / $5,430.62 / $6,516.74
| Facility | | $5,430.62 | $5,430.62 | $6,516.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,873.74 / $2,479.94 / $3,012.83
| Professional | | $1,873.74 | $2,479.94 | $3,012.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,337.37 / $4,337.37 / $4,337.37
| Facility | | $4,337.37 | $4,337.37 | $4,337.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,361.67 / $3,392.81 / $4,174.63
| Professional | | $2,361.67 | $3,392.81 | $4,174.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,667.00 / $6,957.00
| Facility | | $1,565.00 | $2,667.00 | $6,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.73 / $3,075.96 / $4,248.53
| Professional | | $2,079.73 | $3,075.96 | $4,248.53 |