- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.31 / $2,119.31 / $2,543.17
| Facility | | $2,119.31 | $2,119.31 | $2,543.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.03 / $1,644.54 / $2,284.62
| Professional | | $1,549.03 | $1,644.54 | $2,284.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,763.92 / $3,763.92 / $4,461.75
| Facility | | $3,763.92 | $3,763.92 | $4,461.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.37 / $2,048.37 / $2,198.38
| Professional | | $2,048.37 | $2,048.37 | $2,198.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $2,326.75
| Facility | | $2,326.75 | $2,326.75 | $2,326.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $1,698.53 / $2,480.44
| Professional | | $1,698.53 | $1,698.53 | $2,480.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,047.47 / $3,047.47 / $9,406.02
| Professional | | $3,047.47 | $3,047.47 | $9,406.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.84 / $1,877.77 / $2,229.61
| Professional | | $1,251.84 | $1,877.77 | $2,229.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,459.16 / $2,705.08 / $3,442.82
| Professional | | $2,459.16 | $2,705.08 | $3,442.82 |