- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,082.48 / $2,082.48 / $2,498.98
| Facility | | $2,082.48 | $2,082.48 | $2,498.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.45 / $1,615.97 / $2,082.48
| Professional | | $1,534.45 | $1,615.97 | $2,082.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,698.48 / $3,698.48 / $4,384.18
| Facility | | $3,698.48 | $3,698.48 | $4,384.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.14 / $1,929.14 / $2,015.08
| Professional | | $1,929.14 | $1,929.14 | $2,015.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $2,425.11
| Facility | | $2,425.11 | $2,425.11 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $1,770.33 / $2,497.86
| Professional | | $1,770.33 | $1,770.33 | $2,497.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,994.50 / $2,994.50 / $9,242.52
| Professional | | $2,994.50 | $2,994.50 | $9,242.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.08 / $1,845.13 / $2,427.57
| Professional | | $1,230.08 | $1,845.13 | $2,427.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,770.04 / $3,047.04 / $3,878.06
| Professional | | $2,770.04 | $3,047.04 | $3,878.06 |