- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,879.01 / $7,250.48 / $10,875.70
| Facility | | $3,879.01 | $7,250.48 | $10,875.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,936.44 / $2,936.44 / $3,523.73
| Professional | | $2,936.44 | $2,936.44 | $3,523.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.57 / $10,779.07 / $17,077.08
| Facility | | $2,838.57 | $10,779.07 | $17,077.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.88 / $2,900.19 / $19,217.40
| Professional | | $1,993.88 | $2,900.19 | $19,217.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,508.06 / $3,230.08 / $4,199.10
| Facility | | $1,508.06 | $3,230.08 | $4,199.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.04 / $3,021.04 / $3,021.04
| Professional | | $3,021.04 | $3,021.04 | $3,021.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.04 / $3,021.04 / $3,021.04
| Professional | | $3,021.04 | $3,021.04 | $3,021.04 |