- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,235.94
| Facility | | $2,454.71 | $2,454.71 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $3,235.94
| Professional | | $1,380.38 | $1,862.09 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,715.35 / $4,073.80
| Professional | | $2,818.38 | $3,715.35 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $5,495.41
| Professional | | $4,466.84 | $4,466.84 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,311.31 / $16,595.87
| Facility | | $1,380.38 | $3,311.31 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,698.24 / $3,388.44
| Professional | | $1,348.96 | $1,698.24 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,128.61 / $5,128.61
| Facility | | $2,041.74 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,344.23 / $4,073.80
| Professional | | $1,202.26 | $2,344.23 | $4,073.80 |