- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,584.89 / $8,511.38
| Facility | | $1,548.82 | $1,584.89 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,548.82 / $3,890.45
| Professional | | $1,412.54 | $1,548.82 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $4,365.16
| Professional | | $3,019.95 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,951.21 / $4,897.79
| Professional | | $1,659.59 | $2,951.21 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $2,951.21
| Facility | | $1,584.89 | $2,089.30 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,630.27 / $12,022.64
| Professional | | $1,513.56 | $2,630.27 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,754.23 / $3,981.07
| Professional | | $1,479.11 | $2,754.23 | $3,981.07 |