- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,422.72 / $5,816.00 / $33,219.11
| Facility | | $3,422.72 | $5,816.00 | $33,219.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.90 / $1,191.90 / $1,393.50
| Professional | | $1,191.90 | $1,191.90 | $1,393.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.08 / $1,389.18 / $2,451.40
| Professional | | $1,164.08 | $1,389.18 | $2,451.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.34 / $1,425.03 / $3,042.67
| Professional | | $1,125.34 | $1,425.03 | $3,042.67 |