- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,358.83 / $2,358.83 / $2,830.60
| Facility | | $2,358.83 | $2,358.83 | $2,830.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.59 / $1,830.39 / $2,358.83
| Professional | | $1,725.59 | $1,830.39 | $2,358.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,189.25 / $4,189.25 / $4,965.93
| Facility | | $4,189.25 | $4,189.25 | $4,965.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,072.57 / $2,072.57 / $2,164.90
| Professional | | $2,072.57 | $2,072.57 | $2,164.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,782.58 / $2,782.58 / $2,782.58
| Facility | | $2,782.58 | $2,782.58 | $2,782.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.28 / $2,031.28 / $2,782.58
| Professional | | $2,031.28 | $2,031.28 | $2,782.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,391.85 / $3,391.85 / $10,468.94
| Professional | | $3,391.85 | $3,391.85 | $10,468.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.31 / $2,089.96 / $2,549.48
| Professional | | $1,393.31 | $2,089.96 | $2,549.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,137.60 / $3,451.36 / $4,392.64
| Professional | | $3,137.60 | $3,451.36 | $4,392.64 |