- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,052.69 / $5,131.72 / $22,153.60
| Facility | | $2,052.69 | $5,131.72 | $22,153.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.69 / $3,020.94 / $3,679.35
| Professional | | $2,052.69 | $3,020.94 | $3,679.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,785.86 / $8,536.74 / $17,747.43
| Facility | | $3,785.86 | $8,536.74 | $17,747.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,307.23 / $4,501.47 / $8,306.01
| Professional | | $2,307.23 | $4,501.47 | $8,306.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $4,066.65 / $5,615.85
| Professional | | $2,711.10 | $4,066.65 | $5,615.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,702.00 / $8,702.00 / $8,702.00
| Facility | | $8,702.00 | $8,702.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $3,950.46
| Professional | | $1,626.66 | $2,323.80 | $3,950.46 |