- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,327.07 / $2,908.84 / $16,793.70
| Facility | | $2,327.07 | $2,908.84 | $16,793.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,327.07 / $2,714.92 / $3,490.61
| Professional | | $2,327.07 | $2,714.92 | $3,490.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,914.38 / $2,552.50 / $5,558.78
| Facility | | $1,914.38 | $2,552.50 | $5,558.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,724.08 / $4,724.08 / $5,659.99
| Professional | | $4,724.08 | $4,724.08 | $5,659.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,327.07 / $2,327.07 / $3,390.07
| Professional | | $2,327.07 | $2,327.07 | $3,390.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,878.45 / $3,878.45 / $5,817.68
| Facility | | $3,878.45 | $3,878.45 | $5,817.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.46 / $1,628.95 / $8,067.18
| Professional | | $1,357.46 | $1,628.95 | $8,067.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.16 / $239.16 / $239.16
| Professional | | $239.16 | $239.16 | $239.16 |