- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $4,897.79
| Facility | | $2,187.76 | $2,187.76 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $2,187.76
| Professional | | $1,202.26 | $1,621.81 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,630.78 / $5,888.44
| Facility | | $2,754.23 | $3,630.78 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,318.26 / $2,818.38
| Professional | | $870.96 | $1,318.26 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,548.13 / $12,589.25
| Facility | | $1,445.44 | $3,548.13 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,981.07 / $4,786.30
| Professional | | $2,290.87 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,318.26 / $3,890.45
| Professional | | $1,047.13 | $1,318.26 | $3,890.45 |