- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $21,379.62
| Facility | | $2,630.27 | $2,630.27 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,630.27 / $2,818.38
| Professional | | $1,778.28 | $2,630.27 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,235.94 / $3,548.13
| Professional | | $2,884.03 | $3,235.94 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,888.44 / $13,489.63
| Facility | | $5,623.41 | $5,888.44 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $7,079.46
| Professional | | $3,981.07 | $3,981.07 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $4,168.69
| Facility | | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,584.89 / $4,365.16
| Professional | | $1,479.11 | $1,584.89 | $4,365.16 |