- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,015.54 / $2,015.54 / $5,175.04
| Facility | | $2,015.54 | $2,015.54 | $5,175.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,015.54 / $2,505.85 / $5,175.04
| Professional | | $2,015.54 | $2,505.85 | $5,175.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,221.09 / $6,221.09 / $6,221.09
| Facility | | $6,221.09 | $6,221.09 | $6,221.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,872.13 / $2,872.13 / $6,268.35
| Professional | | $2,872.13 | $2,872.13 | $6,268.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,798.08 / $3,798.08 / $4,579.82
| Facility | | $3,798.08 | $3,798.08 | $4,579.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $3,716.46 / $4,111.52
| Professional | | $2,772.60 | $3,716.46 | $4,111.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,459.48 / $4,976.87 / $8,087.42
| Professional | | $3,459.48 | $4,976.87 | $8,087.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.52 / $2,386.52 / $3,909.01
| Professional | | $2,168.52 | $2,386.52 | $3,909.01 |