- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,105.38 / $5,588.74 / $20,371.20
| Facility | | $4,105.38 | $5,588.74 | $20,371.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.80 / $4,608.87 / $5,034.89
| Professional | | $2,323.80 | $4,608.87 | $5,034.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,054.26 / $6,926.09 / $9,735.56
| Facility | | $4,054.26 | $6,926.09 | $9,735.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.91 / $4,453.95 / $5,577.12
| Professional | | $597.91 | $4,453.95 | $5,577.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,873.00 / $3,873.00 / $3,873.00
| Facility | | $3,873.00 | $3,873.00 | $3,873.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.84 / $7,430.22 / $27,353.81
| Facility | | $4,052.84 | $7,430.22 | $27,353.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,085.34 / $5,034.89
| Professional | | $1,626.66 | $2,085.34 | $5,034.89 |