- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,754.23
| Facility | | $2,041.74 | $2,041.74 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,659.59 / $2,754.23
| Professional | | $1,445.44 | $1,659.59 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,090.30 / $3,388.44
| Professional | | $2,290.87 | $3,090.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $4,786.30
| Professional | | $3,801.89 | $3,801.89 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,754.23 / $14,791.08
| Facility | | $1,479.11 | $2,754.23 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,380.38 / $2,818.38
| Professional | | $1,122.02 | $1,380.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,570.88 / $4,570.88
| Facility | | $1,819.70 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,089.30 / $3,548.13
| Professional | | $1,096.48 | $2,089.30 | $3,548.13 |