- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,498.61 / $2,498.61 / $2,998.33
| Facility | | $2,498.61 | $2,498.61 | $2,998.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.87 / $1,981.68 / $2,988.67
| Professional | | $1,938.87 | $1,981.68 | $2,988.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,437.52 / $4,437.52 / $5,260.24
| Facility | | $4,437.52 | $4,437.52 | $5,260.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.81 / $2,731.58 / $2,731.58
| Professional | | $2,591.81 | $2,731.58 | $2,731.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $2,941.06
| Facility | | $2,941.06 | $2,941.06 | $2,941.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $2,941.06
| Professional | | $2,146.96 | $2,146.96 | $2,941.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,592.86 / $3,592.86 / $11,089.36
| Professional | | $3,592.86 | $3,592.86 | $11,089.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.89 / $2,213.83 / $3,176.01
| Professional | | $1,475.89 | $2,213.83 | $3,176.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,323.56 / $3,655.92 / $4,652.97
| Professional | | $3,323.56 | $3,655.92 | $4,652.97 |