- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,052.69 / $5,131.72 / $22,153.60
| Facility | | $2,052.69 | $5,131.72 | $22,153.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.69 / $3,098.40 / $3,679.35
| Professional | | $2,052.69 | $3,098.40 | $3,679.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,785.86 / $8,536.74 / $17,747.43
| Facility | | $3,785.86 | $8,536.74 | $17,747.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,265.71 / $2,265.71 / $2,265.71
| Professional | | $2,265.71 | $2,265.71 | $2,265.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,066.65 / $5,073.63 / $7,056.61
| Professional | | $4,066.65 | $5,073.63 | $7,056.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,711.10 / $2,711.10 / $13,785.00
| Facility | | $2,711.10 | $2,711.10 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $3,950.46
| Professional | | $1,626.66 | $2,323.80 | $3,950.46 |