- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,290.87 / $3,630.78
| Professional | | $1,778.28 | $2,290.87 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $5,623.41
| Facility | | $2,691.53 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $5,011.87
| Professional | | $2,951.21 | $2,951.21 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $7,585.78 / $7,585.78
| Facility | | $3,019.95 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $22,908.68
| Professional | | $2,187.76 | $2,187.76 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,754.23 / $4,786.30
| Facility | | $2,570.40 | $2,754.23 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,884.03 / $3,801.89
| Professional | | $2,137.96 | $2,884.03 | $3,801.89 |