- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,908.84 / $2,908.84 / $23,736.10
| Facility | | $2,908.84 | $2,908.84 | $23,736.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,908.84 / $2,908.84 / $3,025.19
| Professional | | $2,908.84 | $2,908.84 | $3,025.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,102.76 / $3,102.76 / $3,102.76
| Professional | | $3,102.76 | $3,102.76 | $3,102.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,554.57 / $12,337.35 / $14,099.83
| Facility | | $6,554.57 | $12,337.35 | $14,099.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,501.25 / $4,501.25 / $4,946.92
| Professional | | $4,501.25 | $4,501.25 | $4,946.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,460.22 / $7,883.73 / $7,883.73
| Professional | | $4,460.22 | $7,883.73 | $7,883.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $2,327.07 / $6,166.74
| Professional | | $1,628.95 | $2,327.07 | $6,166.74 |