- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,548.13
| Facility | | $2,187.76 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,778.28 / $2,137.96
| Professional | | $1,548.82 | $1,778.28 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.30 / $1,047.13 / $1,445.44
| Professional | | $12.30 | $1,047.13 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $3,162.28
| Professional | | $2,511.89 | $2,511.89 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,187.76 / $2,691.53
| Professional | | $1,318.26 | $2,187.76 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,778.28 / $2,187.76
| Professional | | $1,548.82 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $3,162.28
| Professional | | $1,122.02 | $1,318.26 | $3,162.28 |