- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,158.13 / $2,158.13 / $2,589.76
| Facility | | $2,158.13 | $2,158.13 | $2,589.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.66 / $1,711.63 / $2,158.13
| Professional | | $1,674.66 | $1,711.63 | $2,158.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,832.80 / $3,832.80 / $4,543.39
| Facility | | $3,832.80 | $3,832.80 | $4,543.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.16 / $2,143.16 / $2,238.63
| Professional | | $2,143.16 | $2,143.16 | $2,238.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,540.30 / $2,540.30 / $2,540.30
| Facility | | $2,540.30 | $2,540.30 | $2,540.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.42 / $1,854.42 / $2,616.51
| Professional | | $1,854.42 | $1,854.42 | $2,616.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,103.25 / $3,103.25 / $9,578.18
| Professional | | $3,103.25 | $3,103.25 | $9,578.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.76 / $1,912.15 / $2,636.31
| Professional | | $1,274.76 | $1,912.15 | $2,636.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.65 / $3,157.72 / $4,018.91
| Professional | | $2,870.65 | $3,157.72 | $4,018.91 |