- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,280.09 / $2,280.09 / $5,854.28
| Facility | | $2,280.09 | $2,280.09 | $5,854.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.09 / $3,594.10 / $5,854.28
| Professional | | $2,280.09 | $3,594.10 | $5,854.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,037.63 / $7,037.63 / $7,037.63
| Facility | | $7,037.63 | $7,037.63 | $7,037.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,226.82 / $4,279.66 / $9,383.51
| Professional | | $4,226.82 | $4,279.66 | $9,383.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.47 / $4,697.47 / $5,180.93
| Facility | | $4,697.47 | $4,697.47 | $5,180.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $4,697.47
| Professional | | $3,429.16 | $3,429.16 | $4,697.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,913.55 / $5,630.10 / $9,148.92
| Professional | | $3,913.55 | $5,630.10 | $9,148.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,749.08 / $3,511.00 / $5,410.34
| Professional | | $2,749.08 | $3,511.00 | $5,410.34 |