- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,352.32 / $5,352.32 / $5,352.32
| Facility | | $5,352.32 | $5,352.32 | $5,352.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.09 / $1,945.92 / $7,692.62
| Professional | | $1,755.09 | $1,945.92 | $7,692.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,716.54 / $1,774.31 / $2,028.04
| Professional | | $1,716.54 | $1,774.31 | $2,028.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,076.35 / $3,076.35 / $3,076.35
| Facility | | $3,076.35 | $3,076.35 | $3,076.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.09 / $2,074.31 / $4,169.17
| Professional | | $1,469.09 | $2,074.31 | $4,169.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,662.44 / $2,193.48 / $3,672.84
| Professional | | $1,662.44 | $2,193.48 | $3,672.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.79 / $1,809.95 / $3,281.18
| Professional | | $1,337.79 | $1,809.95 | $3,281.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.91 / $1,911.81 / $2,353.04
| Professional | | $1,113.91 | $1,911.81 | $2,353.04 |