- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,087.66 / $2,087.66 / $5,360.21
| Facility | | $2,087.66 | $2,087.66 | $5,360.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,087.66 / $2,703.23 / $5,360.21
| Professional | | $2,087.66 | $2,703.23 | $5,360.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,443.69 / $6,443.69 / $6,443.69
| Facility | | $6,443.69 | $6,443.69 | $6,443.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,902.58 / $2,952.48 / $6,443.69
| Professional | | $2,902.58 | $2,952.48 | $6,443.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,578.08 / $3,578.08 / $4,743.70
| Facility | | $3,578.08 | $3,578.08 | $4,743.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $5,371.83
| Professional | | $2,612.00 | $2,612.00 | $5,371.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,583.27 / $5,154.95 / $8,376.79
| Professional | | $3,583.27 | $5,154.95 | $8,376.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,887.80 / $2,411.02 / $4,018.36
| Professional | | $1,887.80 | $2,411.02 | $4,018.36 |