- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $15,488.17
| Facility | | $1,862.09 | $1,862.09 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,949.84 / $2,187.76
| Professional | | $1,862.09 | $1,949.84 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,238.72 / $2,454.71
| Professional | | $2,041.74 | $2,238.72 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,265.80 / $9,549.93
| Facility | | $4,073.80 | $4,265.80 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $7,943.28 / $19,498.45
| Professional | | $1,513.56 | $7,943.28 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,897.79 / $5,128.61
| Professional | | $2,884.03 | $4,897.79 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,288.25 / $3,890.45
| Professional | | $1,047.13 | $1,288.25 | $3,890.45 |