- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,398.52 / $3,398.52 / $4,844.37
| Facility | | $3,398.52 | $3,398.52 | $4,844.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.26 / $3,633.28 / $3,633.28
| Professional | | $1,304.26 | $3,633.28 | $3,633.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,266.54 / $7,266.54 / $7,266.54
| Facility | | $7,266.54 | $7,266.54 | $7,266.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,265.67 / $3,633.28 / $3,996.61
| Facility | | $2,265.67 | $3,633.28 | $3,996.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.22 / $1,863.22 / $2,235.86
| Professional | | $1,863.22 | $1,863.22 | $2,235.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,794.83 / $4,658.05 / $6,707.59
| Facility | | $2,794.83 | $4,658.05 | $6,707.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.51 / $2,784.51 / $2,784.51
| Professional | | $2,784.51 | $2,784.51 | $2,784.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $782.55 / $2,142.69
| Professional | | $782.55 | $782.55 | $2,142.69 |