- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,259.19 / $11,838.20 / $15,520.60
| Facility | | $2,259.19 | $11,838.20 | $15,520.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,259.19 / $2,259.19 / $2,259.19
| Professional | | $2,259.19 | $2,259.19 | $2,259.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,145.61 / $2,206.76 / $6,916.52
| Facility | | $2,145.61 | $2,206.76 | $6,916.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,012.25 / $3,012.25 / $3,012.25
| Professional | | $3,012.25 | $3,012.25 | $3,012.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,886.74 / $3,012.25
| Facility | | $2,510.21 | $2,886.74 | $3,012.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,888.20 / $3,751.65
| Professional | | $2,510.21 | $2,888.20 | $3,751.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,054.29 / $2,510.21
| Professional | | $1,054.29 | $1,054.29 | $2,510.21 |