- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,908.84 / $3,288.93 / $10,588.20
| Facility | | $2,908.84 | $3,288.93 | $10,588.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,908.84 / $3,025.19 / $3,451.82
| Professional | | $2,908.84 | $3,025.19 | $3,451.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.79 / $5,119.55 / $7,640.55
| Professional | | $2,016.79 | $5,119.55 | $7,640.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,558.80 / $4,654.14 / $17,240.27
| Facility | | $2,558.80 | $4,654.14 | $17,240.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,878.45 / $3,878.45 / $18,694.13
| Professional | | $3,878.45 | $3,878.45 | $18,694.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,748.50 / $18,422.64 / $18,422.64
| Facility | | $6,748.50 | $18,422.64 | $18,422.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,314.68 / $19,314.68 / $29,088.38
| Professional | | $19,314.68 | $19,314.68 | $29,088.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $2,327.07 / $3,878.45
| Professional | | $1,628.95 | $2,327.07 | $3,878.45 |