- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,245.28 / $2,245.28 / $2,694.34
| Facility | | $2,245.28 | $2,245.28 | $2,694.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.45 / $1,742.28 / $2,245.28
| Professional | | $1,618.45 | $1,742.28 | $2,245.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,987.57 / $3,987.57 / $4,726.87
| Facility | | $3,987.57 | $3,987.57 | $4,726.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.42 / $1,932.42 / $2,027.84
| Professional | | $1,932.42 | $1,932.42 | $2,027.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,476.09 / $2,476.09 / $2,476.09
| Facility | | $2,476.09 | $2,476.09 | $2,476.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.55 / $1,807.55 / $2,550.37
| Professional | | $1,807.55 | $1,807.55 | $2,550.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,228.57 / $3,228.57 / $9,964.98
| Professional | | $3,228.57 | $3,228.57 | $9,964.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.24 / $1,989.36 / $2,385.69
| Professional | | $1,326.24 | $1,989.36 | $2,385.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,986.57 / $3,285.23 / $4,181.20
| Professional | | $2,986.57 | $3,285.23 | $4,181.20 |