- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,043.72 / $2,277.29 / $13,845.90
| Facility | | $2,043.72 | $2,277.29 | $13,845.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,277.29 / $2,277.29 / $2,335.67
| Professional | | $2,277.29 | $2,277.29 | $2,335.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $3,992.55
| Professional | | $2,919.60 | $2,919.60 | $3,992.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,945.47 / $5,920.95 / $16,646.98
| Facility | | $1,945.47 | $5,920.95 | $16,646.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,248.09 / $2,919.60 / $3,123.97
| Facility | | $2,248.09 | $2,919.60 | $3,123.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $2,919.60
| Professional | | $1,226.23 | $1,751.76 | $2,919.60 |