- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,484.42 / $3,484.42 / $3,843.85
| Facility | | $3,484.42 | $3,484.42 | $3,843.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.68 / $3,484.42 / $3,484.42
| Professional | | $1,308.68 | $3,484.42 | $3,484.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,892.04 / $3,276.42 / $3,660.81
| Facility | | $2,892.04 | $3,276.42 | $3,660.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.27 / $1,868.90 / $2,653.83
| Professional | | $1,607.27 | $1,868.90 | $2,653.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.73 / $669.96 / $4,118.39
| Facility | | $318.73 | $669.96 | $4,118.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.05 / $592.65 / $773.03
| Professional | | $438.05 | $592.65 | $773.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,144.44 / $2,466.94 / $3,755.29
| Professional | | $2,144.44 | $2,466.94 | $3,755.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.56 / $2,888.67 / $4,374.26
| Professional | | $1,217.56 | $2,888.67 | $4,374.26 |