- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $19,498.45
| Facility | | $8,511.38 | $8,511.38 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,623.41 / $6,918.31
| Professional | | $4,466.84 | $5,623.41 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $14,125.38 / $22,908.68
| Facility | | $10,471.29 | $14,125.38 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $8,511.38 / $19,054.61
| Professional | | $3,801.89 | $8,511.38 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $28,840.32 / $42,657.95
| Facility | | $5,495.41 | $28,840.32 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $15,488.17 / $18,197.01
| Professional | | $8,912.51 | $15,488.17 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,290.87 / $11,220.18
| Professional | | $2,041.74 | $2,290.87 | $11,220.18 |