- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,311.31 / $5,623.41
| Facility | | $2,818.38 | $3,311.31 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,137.96 / $3,090.30
| Professional | | $2,089.30 | $2,137.96 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,818.38
| Facility | | $2,187.76 | $2,187.76 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $10,471.29 / $25,703.96
| Facility | | $2,137.96 | $10,471.29 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $4,570.88
| Facility | | $1,698.24 | $2,691.53 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $2,511.89
| Professional | | $2,137.96 | $2,290.87 | $2,511.89 |