- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,418.16 / $5,418.16 / $7,805.43
| Facility | | $5,418.16 | $5,418.16 | $7,805.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.46 / $2,101.46 / $2,101.46
| Professional | | $2,101.46 | $2,101.46 | $2,101.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,341.63 / $6,244.35 / $11,708.16
| Facility | | $2,341.63 | $6,244.35 | $11,708.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,612.11 / $5,854.08 / $6,439.49
| Facility | | $3,612.11 | $5,854.08 | $6,439.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,002.09 / $3,002.09 / $3,602.51
| Professional | | $3,002.09 | $3,002.09 | $3,602.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $5,854.08
| Professional | | $30.00 | $30.00 | $5,854.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,503.14 / $6,004.18 / $10,807.52
| Facility | | $4,503.14 | $6,004.18 | $10,807.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,486.95 / $4,486.95 / $4,636.80
| Professional | | $4,486.95 | $4,486.95 | $4,636.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,260.88 / $3,452.40
| Professional | | $1,260.88 | $1,260.88 | $3,452.40 |