- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,371.74 / $2,811.68 / $10,228.90
| Facility | | $1,371.74 | $2,811.68 | $10,228.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,811.68 / $2,845.96 / $2,914.55
| Professional | | $2,811.68 | $2,845.96 | $2,914.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,329.12 / $2,757.06 / $4,402.05
| Facility | | $1,329.12 | $2,757.06 | $4,402.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,257.44 / $3,420.31 / $4,454.55
| Professional | | $3,257.44 | $3,420.31 | $4,454.55 |
- 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
- $1,824.00 / $2,811.68 / $3,771.77
| Facility | | $1,824.00 | $2,811.68 | $3,771.77 |
- 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 |