- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.92 / $2,714.92 / $6,981.21
| Facility | | $2,714.92 | $2,714.92 | $6,981.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,714.92 / $3,645.75 / $3,645.75
| Professional | | $2,714.92 | $3,645.75 | $3,645.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,838.04 / $7,815.08 / $8,726.51
| Professional | | $5,838.04 | $7,815.08 | $8,726.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,456.68 / $4,456.68 / $6,542.62
| Professional | | $4,456.68 | $4,456.68 | $6,542.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,327.07 / $2,947.62 / $6,981.21
| Facility | | $2,327.07 | $2,947.62 | $6,981.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.01 / $4,654.14 / $7,756.90
| Professional | | $1,978.01 | $4,654.14 | $7,756.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $3,956.02 / $6,593.37
| Professional | | $1,628.95 | $3,956.02 | $6,593.37 |