- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,836.42 / $1,836.42 / $14,985.20
| Facility | | $1,836.42 | $1,836.42 | $14,985.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.42 / $1,836.42 / $1,909.88
| Professional | | $1,836.42 | $1,836.42 | $1,909.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.85 / $1,958.85 / $1,958.85
| Professional | | $1,958.85 | $1,958.85 | $1,958.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,978.90 / $4,138.06 / $8,901.52
| Facility | | $3,978.90 | $4,138.06 | $8,901.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,841.91 / $2,841.91 / $3,123.28
| Professional | | $2,841.91 | $2,841.91 | $3,123.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,815.84 / $4,977.18 / $4,977.18
| Professional | | $2,815.84 | $4,977.18 | $4,977.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,101.84 / $3,893.21
| Professional | | $1,028.40 | $1,101.84 | $3,893.21 |