- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,897.79
| Facility | | $3,981.07 | $3,981.07 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,818.38 / $4,897.79
| Professional | | $2,041.74 | $2,818.38 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,025.60 / $6,606.93
| Professional | | $4,570.88 | $6,025.60 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $8,511.38
| Professional | | $6,760.83 | $6,760.83 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,011.87 / $24,547.09
| Facility | | $2,041.74 | $5,011.87 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $5,495.41
| Professional | | $2,041.74 | $2,754.23 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $7,585.78 / $7,585.78
| Facility | | $3,090.30 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,548.13 / $6,309.57
| Professional | | $1,819.70 | $3,548.13 | $6,309.57 |