- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,043.26 / $3,956.24 / $14,074.80
| Facility | | $3,043.26 | $3,956.24 | $14,074.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.60 / $3,473.91 / $3,732.30
| Professional | | $1,722.60 | $3,473.91 | $3,732.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,467.67 / $3,744.07 / $6,950.40
| Facility | | $2,467.67 | $3,744.07 | $6,950.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.20 / $212.16 / $2,780.80
| Professional | | $183.20 | $212.16 | $2,780.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,871.00 / $2,871.00 / $2,871.00
| Facility | | $2,871.00 | $2,871.00 | $2,871.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,004.14 / $7,155.51 / $13,341.70
| Facility | | $3,004.14 | $7,155.51 | $13,341.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.73 / $2,973.49 / $5,907.08
| Professional | | $1,251.73 | $2,973.49 | $5,907.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.25 / $1,435.50 / $3,296.51
| Professional | | $893.25 | $1,435.50 | $3,296.51 |