- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,248.07 / $5,248.07
| Facility | | $2,884.03 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,818.38 / $3,311.31
| Professional | | $1,778.28 | $2,818.38 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $4,168.69
| Professional | | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,623.41 / $10,471.29
| Facility | | $2,884.03 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $16,982.44
| Professional | | $16,982.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- 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 |