- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $6,456.54
| Facility | | $2,951.21 | $2,951.21 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $2,951.21
| Professional | | $1,584.89 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,786.30 / $7,943.28
| Facility | | $3,630.78 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,884.03 / $3,801.89
| Professional | | $1,479.11 | $2,884.03 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,786.30 / $16,595.87
| Facility | | $1,905.46 | $4,786.30 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,370.32 / $6,309.57
| Professional | | $3,981.07 | $5,370.32 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $5,128.61
| Professional | | $1,412.54 | $1,737.80 | $5,128.61 |