- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,801.89 / $3,801.89
| Facility | | $2,041.74 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,041.74 / $2,344.23
| Professional | | $1,737.80 | $2,041.74 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Professional | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,981.07 / $7,585.78
| Facility | | $2,089.30 | $3,981.07 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $12,022.64
| Professional | | $12,022.64 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,174.90 / $3,162.28
| Professional | | $1,122.02 | $1,174.90 | $3,162.28 |