- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,822.13 / $4,555.33 / $19,665.20
| Facility | | $1,822.13 | $4,555.33 | $19,665.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.13 / $2,681.63 / $2,922.29
| Professional | | $1,822.13 | $2,681.63 | $2,922.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,360.63 / $4,349.05 / $11,597.03
| Facility | | $3,360.63 | $4,349.05 | $11,597.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.59 / $4,503.75 / $6,264.00
| Professional | | $2,406.59 | $4,503.75 | $6,264.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,406.59 / $2,406.59 / $8,702.00
| Facility | | $2,406.59 | $2,406.59 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.59 / $2,406.59 / $2,406.59
| Professional | | $2,406.59 | $2,406.59 | $2,406.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.19 / $2,062.79 / $3,506.74
| Professional | | $1,375.19 | $2,062.79 | $3,506.74 |