- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,884.03 / $3,801.89
| Facility | | $2,511.89 | $2,884.03 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $2,884.03
| Professional | | $1,513.56 | $2,137.96 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $891.25
| Facility | | $549.54 | $660.69 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,454.71 / $3,162.28
| Professional | | $1,621.81 | $2,454.71 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,041.74 / $5,495.41
| Facility | | $1,778.28 | $2,041.74 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,511.89 / $2,818.38
| Facility | | $1,174.90 | $2,511.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,174.90 / $1,659.59
| Professional | | $1,047.13 | $1,174.90 | $1,659.59 |