- 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 / $3,020.94 / $3,292.05
| Professional | | $2,052.69 | $3,020.94 | $3,292.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,785.86 / $5,721.37 / $12,195.32
| Facility | | $3,785.86 | $5,721.37 | $12,195.32 |
- 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 / $8,702.00
| Facility | | $2,711.10 | $2,711.10 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $2,711.10 / $2,711.10
| Professional | | $2,711.10 | $2,711.10 | $2,711.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.20 / $2,323.80 / $3,950.46
| Professional | | $1,549.20 | $2,323.80 | $3,950.46 |