- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,317.19 / $12,142.10 / $15,919.10
| Facility | | $2,317.19 | $12,142.10 | $15,919.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,317.19 / $2,317.19 / $2,317.19
| Professional | | $2,317.19 | $2,317.19 | $2,317.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.67 / $2,263.40 / $7,094.05
| Facility | | $2,200.67 | $2,263.40 | $7,094.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,089.58 / $3,089.58 / $3,089.58
| Professional | | $3,089.58 | $3,089.58 | $3,089.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,960.85 / $3,089.58
| Facility | | $2,574.65 | $2,960.85 | $3,089.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,962.50 / $3,848.16
| Professional | | $2,574.65 | $2,962.50 | $3,848.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,081.34 / $1,544.79
| Professional | | $1,081.34 | $1,081.34 | $1,544.79 |