- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,103.46 / $2,103.46 / $5,400.79
| Facility | | $2,103.46 | $2,103.46 | $5,400.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,103.46 / $2,921.62 / $5,400.79
| Professional | | $2,103.46 | $2,921.62 | $5,400.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,492.48 / $6,492.48 / $6,492.48
| Facility | | $6,492.48 | $6,492.48 | $6,492.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,375.82 / $3,259.28 / $7,632.99
| Professional | | $2,375.82 | $3,259.28 | $7,632.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,799.01 / $3,799.01 / $3,799.01
| Facility | | $3,799.01 | $3,799.01 | $3,799.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,229.16 / $3,229.16 / $3,912.98
| Professional | | $3,229.16 | $3,229.16 | $3,912.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,610.39 / $5,398.37 / $9,349.17
| Professional | | $3,610.39 | $5,398.37 | $9,349.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,236.23 / $3,245.53 / $4,401.02
| Professional | | $2,236.23 | $3,245.53 | $4,401.02 |