- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,981.07 / $3,981.07
| Facility | | $2,454.71 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,454.71 / $2,691.53
| Professional | | $2,344.23 | $2,454.71 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,760.83 / $8,511.38
| Professional | | $4,073.80 | $6,760.83 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,981.07 / $16,595.87
| Facility | | $3,311.31 | $3,981.07 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $4,265.80
| Professional | | $1,778.28 | $1,778.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $8,128.31 / $9,772.37
| Professional | | $5,011.87 | $8,128.31 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $4,677.35
| Professional | | $1,479.11 | $2,089.30 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |