- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.67 / $16,457.09 / $21,576.40
| Facility | | $3,140.67 | $16,457.09 | $21,576.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,140.67 / $3,140.67 / $3,140.67
| Professional | | $3,140.67 | $3,140.67 | $3,140.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,982.76 / $3,067.77 / $9,615.15
| Facility | | $2,982.76 | $3,067.77 | $9,615.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,187.56 / $4,187.56 / $4,187.56
| Professional | | $4,187.56 | $4,187.56 | $4,187.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,489.63 / $4,013.07 / $4,187.56
| Facility | | $3,489.63 | $4,013.07 | $4,187.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,489.63 / $4,014.99 / $5,215.29
| Professional | | $3,489.63 | $4,014.99 | $5,215.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $1,465.64 / $2,093.78
| Professional | | $1,465.64 | $1,465.64 | $2,093.78 |