- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $8,511.38
| Facility | | $1,513.56 | $1,513.56 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,513.56 / $3,801.89
| Professional | | $1,380.38 | $1,513.56 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,388.44 / $3,981.07
| Professional | | $2,691.53 | $3,388.44 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $4,677.35
| Professional | | $1,949.84 | $2,884.03 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,570.40 / $4,570.88
| Facility | | $1,513.56 | $2,570.40 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,754.23 / $3,981.07
| Professional | | $1,621.81 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $24,547.09
| Facility | | $1,819.70 | $2,041.74 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,754.23 / $3,715.35
| Professional | | $1,698.24 | $2,754.23 | $3,715.35 |