- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.52 / $10,367.40 / $13,592.40
| Facility | | $1,978.52 | $10,367.40 | $13,592.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.52 / $1,978.52 / $1,978.52
| Professional | | $1,978.52 | $1,978.52 | $1,978.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,879.04 / $1,932.60 / $6,057.23
| Facility | | $1,879.04 | $1,932.60 | $6,057.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,638.02 / $2,638.02 / $2,638.02
| Professional | | $2,638.02 | $2,638.02 | $2,638.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,198.35 / $2,528.10 / $2,638.02
| Facility | | $2,198.35 | $2,528.10 | $2,638.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,198.35 / $2,529.33 / $3,285.49
| Professional | | $2,198.35 | $2,529.33 | $3,285.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $923.31 / $1,319.01
| Professional | | $923.31 | $923.31 | $1,319.01 |