- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,582.68 / $5,082.62 / $10,198.12
| Facility | | $4,582.68 | $5,082.62 | $10,198.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,777.39 / $2,845.96 / $3,229.60
| Professional | | $2,777.39 | $2,845.96 | $3,229.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,473.67 / $5,596.55 / $8,865.71
| Facility | | $1,473.67 | $5,596.55 | $8,865.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.46 / $2,605.94 / $12,622.58
| Professional | | $1,954.46 | $2,605.94 | $12,622.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $2,914.55
| Facility | | $2,914.55 | $2,914.55 | $2,914.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $2,914.55
| Professional | | $2,914.55 | $2,914.55 | $2,914.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,777.39 / $3,908.93 / $15,144.20
| Facility | | $2,777.39 | $3,908.93 | $15,144.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.40 / $2,857.40 / $6,200.56
| Professional | | $2,857.40 | $2,857.40 | $6,200.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.40 / $2,857.40 / $2,857.40
| Professional | | $2,857.40 | $2,857.40 | $2,857.40 |