- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,882.66 / $2,128.66 / $6,852.87
| Facility | | $1,882.66 | $2,128.66 | $6,852.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,882.66 / $1,957.96 / $2,384.69
| Professional | | $1,882.66 | $1,957.96 | $2,384.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.31 / $3,514.29 / $4,945.10
| Professional | | $1,305.31 | $3,514.29 | $4,945.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,680.95 / $5,408.68 / $8,962.81
| Facility | | $1,680.95 | $5,408.68 | $8,962.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,510.21 / $12,099.21
| Professional | | $2,510.21 | $2,510.21 | $12,099.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,367.77 / $11,923.50 / $11,923.50
| Facility | | $4,367.77 | $11,923.50 | $11,923.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,500.85 / $12,500.85 / $18,826.58
| Professional | | $12,500.85 | $12,500.85 | $18,826.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $2,510.21
| Professional | | $1,054.29 | $1,506.13 | $2,510.21 |