- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,914.10 / $10,029.90 / $13,149.90
| Facility | | $1,914.10 | $10,029.90 | $13,149.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,914.10 / $1,914.10 / $1,914.10
| Professional | | $1,914.10 | $1,914.10 | $1,914.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,453.98 / $2,523.92 / $7,910.61
| Facility | | $2,453.98 | $2,523.92 | $7,910.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.23 / $3,082.66 / $5,252.86
| Professional | | $1,319.23 | $3,082.66 | $5,252.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,871.00 / $3,301.65 / $11,627.55
| Facility | | $2,871.00 | $3,301.65 | $11,627.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,216.62 / $2,901.16 / $3,441.38
| Professional | | $2,216.62 | $2,901.16 | $3,441.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.25 / $1,205.82 / $1,722.60
| Professional | | $893.25 | $1,205.82 | $1,722.60 |