- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,711.10 / $3,020.94 / $18,367.30
| Facility | | $2,711.10 | $3,020.94 | $18,367.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,020.94 / $3,020.94 / $3,369.51
| Professional | | $3,020.94 | $3,020.94 | $3,369.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,873.00 / $3,873.00 / $5,344.74
| Professional | | $3,873.00 | $3,873.00 | $5,344.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,038.79 / $9,541.14 / $22,083.07
| Facility | | $7,038.79 | $9,541.14 | $22,083.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.33 / $2,989.16 / $4,571.64
| Professional | | $1,758.33 | $2,989.16 | $4,571.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,020.94 / $3,873.00 / $5,615.85
| Facility | | $3,020.94 | $3,873.00 | $5,615.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $1,936.50 / $3,873.00
| Professional | | $1,626.66 | $1,936.50 | $3,873.00 |