- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $5,623.41
| Facility | | $2,570.40 | $2,570.40 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $3,162.28
| Professional | | $1,412.54 | $1,905.46 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,265.80 / $6,918.31
| Facility | | $3,388.44 | $4,265.80 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $8,317.64 / $13,489.63
| Professional | | $1,548.82 | $8,317.64 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,168.69 / $14,791.08
| Facility | | $1,659.59 | $4,168.69 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,677.35 / $5,623.41
| Professional | | $2,691.53 | $4,677.35 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,548.82 / $4,466.84
| Professional | | $1,230.27 | $1,548.82 | $4,466.84 |