- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $2,818.38
| Facility | | $1,348.96 | $2,187.76 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,137.96 / $2,951.21
| Professional | | $1,819.70 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $7,413.10
| Facility | | $5,370.32 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,884.03
| Professional | | $2,187.76 | $2,187.76 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $3,467.37
| Professional | | $1,698.24 | $2,691.53 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,073.80 / $11,748.98
| Facility | | $1,548.82 | $4,073.80 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $3,715.35
| Professional | | $1,737.80 | $2,344.23 | $3,715.35 |