- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,896.96 / $2,113.76 / $12,851.70
| Facility | | $1,896.96 | $2,113.76 | $12,851.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.76 / $2,113.76 / $2,357.66
| Professional | | $2,113.76 | $2,113.76 | $2,357.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $621.22 / $621.22 / $621.22
| Facility | | $621.22 | $621.22 | $621.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,709.95 / $2,845.45 / $3,739.73
| Professional | | $2,709.95 | $2,845.45 | $3,739.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,925.07 / $6,675.97 / $15,451.61
| Facility | | $4,925.07 | $6,675.97 | $15,451.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.76 / $2,709.95 / $3,424.29
| Facility | | $2,113.76 | $2,709.95 | $3,424.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.18 / $1,625.97 / $2,709.95
| Professional | | $1,138.18 | $1,625.97 | $2,709.95 |