- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,055.58 / $5,138.95 / $22,184.70
| Facility | | $2,055.58 | $5,138.95 | $22,184.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.58 / $3,025.19 / $3,296.69
| Professional | | $2,055.58 | $3,025.19 | $3,296.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,791.19 / $4,906.24 / $13,082.56
| Facility | | $3,791.19 | $4,906.24 | $13,082.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,072.37 / $5,080.77 / $7,066.54
| Professional | | $4,072.37 | $5,080.77 | $7,066.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.92 / $2,714.92 / $8,702.00
| Facility | | $2,714.92 | $2,714.92 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,714.92 / $2,714.92 / $2,714.92
| Professional | | $2,714.92 | $2,714.92 | $2,714.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.52 / $2,327.07 / $3,956.02
| Professional | | $1,609.52 | $2,327.07 | $3,956.02 |