- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,769.04 / $6,922.60 / $29,884.70
| Facility | | $2,769.04 | $6,922.60 | $29,884.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.04 / $4,075.19 / $4,440.91
| Professional | | $2,769.04 | $4,075.19 | $4,440.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,107.05 / $7,718.14 / $16,451.78
| Facility | | $5,107.05 | $7,718.14 | $16,451.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,657.22 / $6,844.23 / $9,519.21
| Professional | | $3,657.22 | $6,844.23 | $9,519.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.22 / $3,657.22 / $12,381.00
| Facility | | $3,657.22 | $3,657.22 | $12,381.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,657.22 / $3,657.22 / $3,657.22
| Professional | | $3,657.22 | $3,657.22 | $3,657.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $3,134.76 / $5,329.09
| Professional | | $2,194.33 | $3,134.76 | $5,329.09 |