- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,831.07 / $2,831.07 / $3,397.28
| Facility | | $2,831.07 | $2,831.07 | $3,397.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.36 / $2,196.84 / $2,831.07
| Professional | | $1,783.36 | $2,196.84 | $2,831.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,027.93 / $5,027.93 / $5,960.12
| Facility | | $5,027.93 | $5,027.93 | $5,960.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.26 / $2,396.26 / $2,530.21
| Professional | | $2,396.26 | $2,396.26 | $2,530.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.17 / $2,728.17 / $2,728.17
| Facility | | $2,728.17 | $2,728.17 | $2,728.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $2,728.17
| Professional | | $1,991.56 | $1,991.56 | $2,728.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,070.90 / $4,070.90 / $12,564.83
| Professional | | $4,070.90 | $4,070.90 | $12,564.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,672.26 / $2,508.38 / $3,068.55
| Professional | | $1,672.26 | $2,508.38 | $3,068.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,765.76 / $4,142.34 / $5,272.06
| Professional | | $3,765.76 | $4,142.34 | $5,272.06 |