- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $33,884.42 / $33,884.42
| Facility | | $4,073.80 | $33,884.42 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $4,073.80 / $4,265.80
| Professional | | $588.84 | $4,073.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,365.16 / $4,786.30
| Professional | | $3,981.07 | $4,365.16 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $9,332.54 / $20,892.96
| Facility | | $8,912.51 | $9,332.54 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $11,220.18
| Professional | | $6,309.57 | $6,309.57 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,454.71 / $6,918.31
| Professional | | $2,290.87 | $2,454.71 | $6,918.31 |