- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $6,025.60 / $11,481.54
| Facility | | $1,698.24 | $6,025.60 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,949.84 / $2,691.53
| Professional | | $1,698.24 | $1,949.84 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,570.40 / $3,388.44
| Professional | | $2,454.71 | $2,570.40 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $6,025.60 / $13,803.84
| Facility | | $1,584.89 | $6,025.60 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,041.74 / $3,311.31
| Facility | | $1,584.89 | $2,041.74 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $2,454.71
| Professional | | $1,023.29 | $1,445.44 | $2,454.71 |