- 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 / $3,098.40
| Professional | | $3,020.94 | $3,020.94 | $3,098.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.00 / $3,343.20 / $5,296.33
| Professional | | $3,184.00 | $3,343.20 | $5,296.33 |
- 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 / $14,995.16
| Professional | | $1,758.33 | $2,989.16 | $14,995.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,020.94 / $3,098.40 / $5,615.85
| Facility | | $3,020.94 | $3,098.40 | $5,615.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.15 / $2,130.15 / $2,130.15
| Professional | | $2,130.15 | $2,130.15 | $2,130.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,209.08 / $3,526.79
| Professional | | $1,626.66 | $2,209.08 | $3,526.79 |