- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $4,466.84
| Facility | | $3,467.37 | $3,467.37 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,884.03 / $4,466.84
| Professional | | $2,089.30 | $2,884.03 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,248.07 / $5,754.40
| Professional | | $3,981.07 | $5,248.07 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $7,762.47
| Professional | | $6,165.95 | $6,165.95 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,677.35 / $23,988.33
| Facility | | $2,089.30 | $4,677.35 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $4,786.30
| Professional | | $1,905.46 | $2,398.83 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $7,244.36 / $7,244.36
| Facility | | $2,951.21 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,311.31 / $5,754.40
| Professional | | $1,737.80 | $3,311.31 | $5,754.40 |