- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,617.21 / $2,617.21 / $21,356.50
| Facility | | $2,617.21 | $2,617.21 | $21,356.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,617.21 / $2,617.21 / $2,721.91
| Professional | | $2,617.21 | $2,617.21 | $2,721.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,791.70 / $3,245.36 / $3,245.36
| Professional | | $2,791.70 | $3,245.36 | $3,245.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,670.65 / $5,897.48 / $12,685.68
| Facility | | $5,670.65 | $5,897.48 | $12,685.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,677.28 / $3,677.28 / $4,041.37
| Professional | | $3,677.28 | $3,677.28 | $4,041.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,013.07 / $7,093.37 / $7,093.37
| Professional | | $4,013.07 | $7,093.37 | $7,093.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $2,093.78 / $5,548.51
| Professional | | $1,465.64 | $2,093.78 | $5,548.51 |