- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,884.03
| Facility | | $2,511.89 | $2,511.89 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,819.70 / $2,884.03
| Professional | | $1,479.11 | $1,819.70 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $4,168.69
| Professional | | $2,884.03 | $3,801.89 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $5,011.87
| Professional | | $3,981.07 | $3,981.07 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,884.03 / $15,848.93
| Facility | | $1,513.56 | $2,884.03 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,737.80 / $3,467.37
| Professional | | $1,380.38 | $1,737.80 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,011.87 / $5,011.87
| Facility | | $2,041.74 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,290.87 / $3,630.78
| Professional | | $1,202.26 | $2,290.87 | $3,630.78 |