- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.92 / $3,025.19 / $18,393.20
| Facility | | $2,714.92 | $3,025.19 | $18,393.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,025.19 / $3,025.19 / $3,102.76
| Professional | | $3,025.19 | $3,025.19 | $3,102.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,878.45 / $3,878.45 / $5,303.78
| Professional | | $3,878.45 | $3,878.45 | $5,303.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,048.69 / $9,554.54 / $22,114.12
| Facility | | $7,048.69 | $9,554.54 | $22,114.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.92 / $3,878.45 / $4,809.28
| Facility | | $2,714.92 | $3,878.45 | $4,809.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $2,212.19 / $3,878.45
| Professional | | $1,628.95 | $2,212.19 | $3,878.45 |