- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,568.46 / $2,568.46 / $3,082.16
| Facility | | $2,568.46 | $2,568.46 | $3,082.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,942.72 / $1,993.07 / $3,072.20
| Professional | | $1,942.72 | $1,993.07 | $3,072.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,561.55 / $4,561.55 / $5,407.26
| Facility | | $4,561.55 | $4,561.55 | $5,407.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.42 / $2,578.42 / $2,689.14
| Professional | | $2,578.42 | $2,578.42 | $2,689.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,001.39 / $2,741.63
| Professional | | $2,001.39 | $2,001.39 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,693.28 / $3,693.28 / $11,399.31
| Professional | | $3,693.28 | $3,693.28 | $11,399.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.14 / $2,275.69 / $3,693.28
| Professional | | $1,517.14 | $2,275.69 | $3,693.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,416.45 / $3,758.10 / $4,783.03
| Professional | | $3,416.45 | $3,758.10 | $4,783.03 |