- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,438.96 / $12,780.10 / $16,755.70
| Facility | | $2,438.96 | $12,780.10 | $16,755.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,438.96 / $2,438.96 / $2,438.96
| Professional | | $2,438.96 | $2,438.96 | $2,438.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,316.33 / $2,382.35 / $7,466.87
| Facility | | $2,316.33 | $2,382.35 | $7,466.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.94 / $3,251.94 / $3,251.94
| Professional | | $3,251.94 | $3,251.94 | $3,251.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,709.95 / $3,116.44 / $3,251.94
| Facility | | $2,709.95 | $3,116.44 | $3,251.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,709.95 / $3,118.00 / $4,050.15
| Professional | | $2,709.95 | $3,118.00 | $4,050.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.18 / $1,138.18 / $1,625.97
| Professional | | $1,138.18 | $1,138.18 | $1,625.97 |