- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,443.04 / $2,443.04 / $2,931.65
| Facility | | $2,443.04 | $2,443.04 | $2,931.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.75 / $1,915.68 / $2,922.20
| Professional | | $1,895.75 | $1,915.68 | $2,922.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,338.82 / $4,338.82 / $5,143.24
| Facility | | $4,338.82 | $4,338.82 | $5,143.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,469.21 / $2,469.21 / $2,604.23
| Professional | | $2,469.21 | $2,469.21 | $2,604.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,550.04 / $2,550.04 / $2,550.04
| Facility | | $2,550.04 | $2,550.04 | $2,550.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.53 / $1,861.53 / $2,990.32
| Professional | | $1,861.53 | $1,861.53 | $2,990.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,512.95 / $3,512.95 / $10,842.72
| Professional | | $3,512.95 | $3,512.95 | $10,842.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.06 / $2,164.59 / $3,063.81
| Professional | | $1,443.06 | $2,164.59 | $3,063.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,249.63 / $3,574.59 / $4,549.47
| Professional | | $3,249.63 | $3,574.59 | $4,549.47 |