- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,578.48 / $2,578.48 / $21,040.40
| Facility | | $2,578.48 | $2,578.48 | $21,040.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.48 / $2,578.48 / $2,681.63
| Professional | | $2,578.48 | $2,578.48 | $2,681.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,750.38 / $2,750.38 / $2,750.38
| Professional | | $2,750.38 | $2,750.38 | $2,750.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,810.19 / $10,936.44 / $12,498.79
| Facility | | $5,810.19 | $10,936.44 | $12,498.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,989.85 / $3,989.85 / $4,384.88
| Professional | | $3,989.85 | $3,989.85 | $4,384.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,953.68 / $6,988.38 / $6,988.38
| Professional | | $3,953.68 | $6,988.38 | $6,988.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.95 / $2,062.79 / $5,466.39
| Professional | | $1,443.95 | $2,062.79 | $5,466.39 |