- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,134.76 / $3,918.45 / $22,622.50
| Facility | | $3,134.76 | $3,918.45 | $22,622.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,847.41 / $3,657.22 / $4,702.14
| Professional | | $2,847.41 | $3,657.22 | $4,702.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,578.83 / $3,610.36 / $19,645.00
| Facility | | $2,578.83 | $3,610.36 | $19,645.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,364.01 / $6,364.01 / $7,624.80
| Professional | | $6,364.01 | $6,364.01 | $7,624.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,134.76 / $3,134.76 / $4,440.91
| Professional | | $3,134.76 | $3,134.76 | $4,440.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,224.60 / $5,224.60 / $5,224.60
| Facility | | $5,224.60 | $5,224.60 | $5,224.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.61 / $2,194.33 / $8,186.22
| Professional | | $1,828.61 | $2,194.33 | $8,186.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,134.76 / $3,134.76 / $3,134.76
| Professional | | $3,134.76 | $3,134.76 | $3,134.76 |