- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,189.69 / $2,919.60 / $7,007.04
| Facility | | $2,189.69 | $2,919.60 | $7,007.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.50 / $2,160.50 / $3,123.97
| Professional | | $2,160.50 | $2,160.50 | $3,123.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.74 / $1,897.74 / $7,799.71
| Facility | | $1,897.74 | $1,897.74 | $7,799.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,556.09 / $3,556.09 / $4,260.59
| Professional | | $3,556.09 | $3,556.09 | $4,260.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.50 / $2,919.60 / $4,904.93
| Facility | | $2,160.50 | $2,919.60 | $4,904.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,226.23 / $10,963.77
| Professional | | $1,226.23 | $1,226.23 | $10,963.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,226.23 / $1,868.54
| Professional | | $1,226.23 | $1,226.23 | $1,868.54 |