- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.19 / $2,126.19 / $4,518.17
| Facility | | $2,126.19 | $2,126.19 | $4,518.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.22 / $1,722.22 / $1,722.22
| Professional | | $1,722.22 | $1,722.22 | $1,722.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,782.55 / $13,602.15 / $15,854.65
| Facility | | $11,782.55 | $13,602.15 | $15,854.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.15 / $21.15 / $1,807.27
| Professional | | $21.15 | $21.15 | $1,807.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.19 / $2,126.19 / $2,147.46
| Professional | | $2,126.19 | $2,126.19 | $2,147.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.19 / $2,126.19 / $3,444.44
| Facility | | $2,126.19 | $2,126.19 | $3,444.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.22 / $1,722.22 / $2,126.19
| Professional | | $1,722.22 | $1,722.22 | $2,126.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.35 / $1,275.72 / $3,189.30
| Professional | | $1,084.35 | $1,275.72 | $3,189.30 |