- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,789.12 / $14,615.00 / $19,161.30
| Facility | | $2,789.12 | $14,615.00 | $19,161.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,789.12 / $2,789.12 / $2,789.12
| Professional | | $2,789.12 | $2,789.12 | $2,789.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,145.61 / $2,206.76 / $6,916.52
| Facility | | $2,145.61 | $2,206.76 | $6,916.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.44 / $2,994.69 / $4,592.66
| Professional | | $1,153.44 | $2,994.69 | $4,592.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,886.74 / $11,295.94
| Facility | | $2,510.21 | $2,886.74 | $11,295.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,536.59 / $3,008.86 / $3,433.34
| Professional | | $2,536.59 | $3,008.86 | $3,433.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,301.58 / $1,506.13
| Professional | | $1,054.29 | $1,301.58 | $1,506.13 |