- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,552.42 / $6,026.86 / $9,312.70
| Facility | | $3,552.42 | $6,026.86 | $9,312.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,974.93 / $2,974.93 / $2,974.93
| Professional | | $2,974.93 | $2,974.93 | $2,974.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,578.27 / $4,777.39 / $6,613.55
| Facility | | $2,578.27 | $4,777.39 | $6,613.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,333.28 / $2,916.60 / $3,923.73
| Facility | | $2,333.28 | $2,916.60 | $3,923.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,749.96 / $14,583.00
| Professional | | $1,224.97 | $1,749.96 | $14,583.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,020.65 / $8,020.65 / $8,020.65
| Facility | | $8,020.65 | $8,020.65 | $8,020.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,749.96 / $4,374.89
| Professional | | $1,224.97 | $1,749.96 | $4,374.89 |