- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,548.13 / $3,981.07
| Professional | | $2,818.38 | $3,548.13 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,011.87 / $6,025.60
| Professional | | $4,897.79 | $5,011.87 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $3,630.78
| Facility | | $2,630.27 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,630.78
| Professional | | $3,090.30 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $5,248.07 / $5,248.07
| Facility | | $64.57 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $436.52 / $2,951.21
| Facility | | $295.12 | $436.52 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $3,311.31
| Professional | | $1,479.11 | $2,187.76 | $3,311.31 |