- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $17,378.01
| Facility | | $6,309.57 | $6,309.57 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,737.80 / $2,187.76
| Professional | | $1,380.38 | $1,737.80 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,786.30 / $14,454.40
| Facility | | $4,365.16 | $4,786.30 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $1,621.81 / $2,344.23
| Professional | | $302.00 | $1,621.81 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,943.28 / $10,964.78
| Facility | | $4,073.80 | $7,943.28 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $4,786.30
| Professional | | $2,511.89 | $2,511.89 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $2,511.89
| Professional | | $1,513.56 | $1,513.56 | $2,511.89 |