- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $6,309.57
| Facility | | $2,454.71 | $2,454.71 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,454.71 / $2,884.03
| Professional | | $2,344.23 | $2,454.71 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,079.46 / $7,943.28
| Professional | | $5,128.61 | $7,079.46 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $5,128.61
| Professional | | $4,073.80 | $4,073.80 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,168.69 / $16,595.87
| Facility | | $2,454.71 | $4,168.69 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $6,025.60
| Professional | | $1,479.11 | $1,778.28 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,548.13 / $5,128.61
| Professional | | $1,479.11 | $3,548.13 | $5,128.61 |