- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,745.72 / $2,745.72 / $2,745.72
| Facility | | $2,745.72 | $2,745.72 | $2,745.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.64 / $1,911.58 / $3,058.53
| Professional | | $1,092.64 | $1,911.58 | $3,058.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,590.21 / $3,917.10 / $4,154.83
| Facility | | $3,590.21 | $3,917.10 | $4,154.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,888.03 / $3,888.03 / $3,888.03
| Professional | | $3,888.03 | $3,888.03 | $3,888.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,782.58 / $2,782.58 / $2,782.58
| Facility | | $2,782.58 | $2,782.58 | $2,782.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.28 / $2,031.28 / $6,233.44
| Professional | | $2,031.28 | $2,031.28 | $6,233.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.64 / $2,942.86 / $17,790.55
| Facility | | $1,092.64 | $2,942.86 | $17,790.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.32 / $2,090.79 / $4,665.07
| Professional | | $1,128.32 | $2,090.79 | $4,665.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.48 / $1,821.71 / $2,608.07
| Professional | | $1,214.48 | $1,821.71 | $2,608.07 |